• Endocrine & metabolic
• Obesity
  Underweight < 18.5
  Optimal 19-25
  Overweight 25-30
  Obese > 30
  Morbidly obese > 40
  Super-morbidly obese > 55
• Hypothermia (< 35)
  Mild 33-35
  Moderate 28-33
  Severe < 25
• Phaeochromocytoma
  10% bilateral, 10% malignant, 10% familial, 10% in childhood. Usually presents in 40s - 50s. Commoner in females. Associated with MEN IIA & IIB. Diagnosis with VMA and metanephrine urine collections.
• Adrenaline, NA, dopamine or a combination of these
• α-block first with prazocin then β-block with labetalol or atenolol to achieve BP of below 140/90
• Mineralocorticoids (aldosterone) and glucocorticoids (cortisol, corticosterone) are C21; androgens (DHEA, androstenedione) are C19. Both are derived form cholesterol.
• GC - cause liver protein catabolism, CV response to catecholamines, have weak MC effects and immunosuppression.
• MC cause Na⁺ reabsorption with K⁺/H⁺ loss
• Adrenal cortex
  All 3 zones secrete corticosterone
• Glomerulosa
• Predominantly aldosterone
• Fasciculata
• Predominantly cortisol
• Reticularis
• Predominantly cortisol
• Hyperaldosteronism
• Primary (Conn's)
• Due to adenoma (60%), adrenal hyperplasia (30%), carcinoma (10%)
• Aldosterone:renin ratio is >400ηg/dl
  MRI adrenals
  Scintigraphy with 131I or 75Se labelled precursors of aldosterone to differentiate adenoma from hyperplasia
• Hyperplasia is treated by spironolactone, adenomas by surgery
• Secondary (CCF/cirrhosis)
• Addison's disease
• Autoimmune
  Malignant
  Adrenalectomy
  Meningococcal
  TB
  Withdrawal of corticosteroids
• Diagnosis by SST - tetracosactrin 250μcg is given IV. Cortisol measured at 30 & 60 mins. Low cortisol & weak response suggests insufficiency
  Adrenal ABs & imaging may determine cause
• Treatment - IV hydrocortisone 200mg bonus and 100mg every 6 hrs.
• Cushing's (excess GC)
• Syndrome is the clinical appearance, disease is due to excess ACTH due to pituitary adenoma or adrenal carcinoma (20-30%) or ectopic secretion (oat cell carcinoma)
• Screening - 24hr urinary cortisol (>700 mmol/L)
  Dexamethasone suppression test (1mg at night) normally causes suppression of cortisol on 9am serum cortisol
• Diagnosis of cause: high dose dexamethasone suppression test, 8 doses of 2mg dex over 48hrs. Suppression of cortisol in pituitary dependent Cushing's but not in ectopic ACTH.
  Serum ACTH level
  MRI pituitary, CT adrenals etc
  Petrosal sinus venous sample after CRH stimulation
• Treatment: transphenoidal removal, removal of adenoma, metyrapone (cortisol synthesis inhibitor) for cases not amenable for surgery