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http://www.cs.odu.edu/~iat/papers/?autumn=online-hummorist-essays online hummorist essays Elevated with those from plasma acth and concentration or in primary adrenal plasma renin plasma aldosterone concentration activity insufficiency but is usually •• secondary or tertiary tests not present in secondary adrenal insufficiency. Or tertiary adrenal plasma renin insufficiency concentration or activity is usually normal acth, adrenocorticotropic hormone or corticotropin. Hpa, hypothalamic-pituitary-adrenal. Im, intramuscularly. Iv, intravenously primary adrenal insufficiency may be accompanied by a reduction in aldosterone and androgen production. Secondary adrenal insufficiency occurs as a result of pituitary gland dysfunction, whereby decreased production and secretion of acth leads to a decrease in cortisol synthesis. Tertiary adrenal insufficiency is a disorder of the hypothalamus that results in decreased production and release of crh, which in turn decreases pituitary acth production and release. In contrast to addison disease, aldosterone production is unaffected in the secondary and tertiary forms of the disease. Chronic adrenal insufficiency often has a good prognosis if diagnosed early and treated appropriately. Acute adrenal insufficiency (ie, adrenal crisis) results from the body’s inability to sufficiently increase endogenous cortisol during periods of excessive physiologic stress. Adrenal crisis can occur when patients with chronic adrenal insufficiency do not receive adequate glucocorticoid replacement during stressful conditions such as those experienced during surgery, infection, fever, acute illness, invasive medical procedures, or trauma. Acute adrenal insufficiency can also result from bilateral adrenal infarction due to hemorrhage, embolus, sepsis, or adrenal vein thrombosis. Patients who are critically ill may also experience impaired hpa axis function, with an overall prevalence rate of 10% to 20%, and as high as 60% in those experiencing septic clinical presentation and diagnosis of acute adrenal insufficiency (adrenal crisis)2,6,8 general •• onset of symptoms is acute and precipitated by excessive physiologic stress or abrupt discontinuation of supraphysiologic doses of chronic glucocorticoid. Symptoms •• severe weakness and fatigue •• abdominal or flank pain signs •• severe dehydration leading to hypotension and shock (circulatory collapse). Hypovolemia may not be responsive to intravenous (iv) hydration and may require the use of vasopressors. •• tachycardia •• nausea, vomiting •• fever •• confusion •• hypoglycemia •• laboratory abnormalities are similar to those observed in chronic adrenal insufficiency. Laboratory tests •• the unstimulated serum cortisol and rapid acth stimulation tests are useful in diagnosis (see table 45–2). The insulin tolerance test is contraindicated due to preexisting hypoglycemia. The metyrapone test is also contraindicated since metyrapone inhibits cortisol production.

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