Addison disease

• pigmentation usually generalized but more prominent over sun-exposed area such as the face,extensor surfaces,elbows,knees,knuckles and scars (which formed after the onset of disease)
• may also affect the palmar crease,mucous membrane,nail beds,vaginal and perianal mucosa
  

picture from : http://www.uptodate.com

Case 1 : Addison disease

Case 1 : Addison disease

A 12-year-old girl presented with vague abdominal discomfort for 6 months. She had noticed occasional diarrhoea but had not passed any blood. She admitted to weight loss (6kg) and anorexia. On examination, she was obviously pigmented, although she thought this was sun induced; however, her buccal mucosa and gums were also brown. There were no other physical signs.

She had a low cortisol level and her response to the adrenocorticotrophic hormone in a Synacthen test was poor. A diagnosis of adrenal cortical failure was made. X-ray of her abdomen showed no calcified areas in either adrenal gland, and her serum contained antibodies to adrenal cortex, consistent with a diagnosis of Addison's disease due to autoimmune adrenalitis. Her serum also contained antibodies to pancreatic islet cells and thyroid microsomes. In view of her young age at presentation and these serum antibodies, she will be followed at yearly intervals to see if she develops other autoimmune endocrinopathies.

from: www.immunologyclinic.com

Adrenal gland

• found at the level of T12
• divided into 2 area : adrenal cortex and adrenal medulla

Adrenal medulla

• form the core of adrenal gland
• made up by chromaffin cells that produce

1. catecholamine : adrenaline and noradrenaline
2. dopamine

Adrenal cortex

• form the outer layer of adrenal gland
• consist of 3 layers : zona glomerulosa ,zona fasciculata, zona reticularis
• zona glomerulosa :
  

1. the outermost layer of the cortex
2. produce mineralocorticoids mainly aldosterone

• zona fasciculata:

1. middle layer
   
2. produce glucocorticoids mainly cortisol

• zona reticularis

1. innermost layer
2. produce small number of androgens
   

atrial pressure

atrial pressure increases when :

• a wave : atrial contraction
• c wave: as ventricle contracts - due probably to bulging of AV valve into atria
• v wave: increases slowly at atrium fills with blood from periphery

atrial pressure reduces when :

• x descent: atrium relaxes and tricuspid valve is pulled downwards
• y descent : tricuspid valve opens and blood flows into right ventricle

cardiac cycle

CARDIAC CYCLE

• one cardiac cycle : one complete cycle that encompasses atrial and ventricle contraction and relaxation

• 

• P wave	atrial depolarization & contraction	fills the ventricles	cuspid valves open while valves of vena cava and pulmonary veins are closed
  QRS complex	atrial repolarization and relaxation & simultaneous ventricular depolarization and contraction	empties the ventricles	cuspid valves are closed while semilunar valves are open
  T wave	ventricular repolarization and relaxation	heart relaxes	cuspid and semilunar valves are closed
  pause	myocardium at rest	atria fill after a pause of some length	valves of vena cava and pulmonary veins open so atria can fill

Chronic obstructive pulmonary disease

Hypothermia

External signs of hypothermia

• indistinct, blurred margin of pink or brownish pinkish
• usually over the extensor surface of the knee,elbow and hip joint
• not in area where hypostasis might occur
• may have necrosis or blister
• may have frost bites
  

1. Pinkish margin occurs because in hypothermia, cells have a lesser degree of oxygen uptake, thus the pinkish margin id due to oxygenated blood that remains in the blood vessel

Internal signs of hypothermia

• gastric ulceration : blackish or brownish
• patches of fat necrosis
• haemorrhagic pancreatitis
• diffuse lung haemorrhage and pulmonary odema