392.2 📚 國考版醫垫國考 / PGY OSCE

392.2.0.1 📌 Cram Sheet

392.2.0.1.1 🔥 高 yield 15
  1. Loss order (倧臎): GH → LH/FSH → TSH → ACTH → ADH
  2. 8 倧原因: tumor / surgery / RT / vascular (apoplexy/Sheehan) / autoimmune (ICI hypophysitis) / infiltrative / infection / trauma / genetic
  3. Replacement 氞遠 cortisol 先 再 T4 (避 adrenal crisis)
  4. Sheehan: post-partum hemorrhage → not lactate + amenorrhea
  5. ICI hypophysitis: ipilimumab > nivolumab/pembrolizumab; ACTH first
  6. Pituitary apoplexy: thunderclap headache + visual + ophthalmoplegia + steroid IV STAT
  7. TBI 30-50% 有 anterior pituitary dysfunction, follow 6-12 mo
  8. Cosyntropin stim: cortisol < 18 (老) / < 14 (newer) → AI
  9. Acute (< 4 wk) post-pituitary surgery: ACTH stim false negative (adrenal not atrophic yet)
  10. Central hypothyroid 甹 free T4 monitor 侍甹 TSH
  11. Secondary AI: no hyperpigmentation, no severe hyperK/hypoNa
  12. Hydrocortisone replacement 15-25 mg/d split AM > midday
  13. Stress dose: 雙倍 for mild; surgery 100 mg IV
  14. Macimorelin oral GH stim (22E)
  15. Adult GHD diagnosis 需 stim test + IGF-1
392.2.0.1.2 🔢 必背
項目 æ•žå­—
Cortisol stim cutoff < 18 (older) / < 14 (newer)
Hydrocortisone daily 15-25 mg split
Free T4 target central hypo 䞊半 normal range (~1.4-1.6)
Stress dose surgery HC 100 mg IV → 50 q6h
TBI follow-up 6-12 mo screen

392.2.0.2 ⭐ 高 yield

392.2.0.2.1 Genetic Hypopituitarism
Gene Defect
PROP1 GH/PRL/TSH/LH/FSH ± ACTH
POU1F1 (Pit-1) GH/PRL/TSH
HESX1 Septo-optic dysplasia
TPIT Isolated ACTH def
KAL1/FGFR1 (Kallmann) GnRH + anosmia
392.2.0.2.2 ICI-induced Endocrinopathies
Drug Endocrinopathy
Ipilimumab (CTLA-4) Hypophysitis (most common)
Pembrolizumab/nivolumab (PD-1) Thyroiditis (most common ICI endocrine) > hypophysitis
Atezolizumab (PD-L1) 各皮
Combo ipi + nivo High rates all
392.2.0.2.3 Apoplexy 重點
  • 突癌 thunderclap headache
  • Visual loss (chiasm)
  • Ophthalmoplegia (cavernous sinus, CN III/IV/VI)
  • Altered consciousness
  • 立即 hydrocortisone 100 mg IV + IV NS
  • Surgery if visual / consciousness compromise
392.2.0.2.4 Stress Dose Steroid
Stress Dose
Mild illness (fever > 38) 2× daily HC × 24-48 h
Moderate (vomiting, minor surgery) 50 mg HC IV q6h × 24 h
Major surgery 100 mg IV → 50 q6h × 24 h, taper
Adrenal crisis 100 mg IV STAT + NS
392.2.0.2.5 Replacement Order (Memorize!)
  1. Hydrocortisone first (cortisol)
  2. Levothyroxine (T4)
  3. Sex steroids (testosterone / estrogen + progestin)
  4. GH if indicated
  5. Desmopressin if DI

392.2.0.3 🎯 自我檢枬

  1. Loss of axis order? → GH/LH-FSH/TSH/ACTH/ADH
  2. Sheehan first sign? → No post-partum lactation
  3. ICI hypophysitis 最高 risk drug? → Ipilimumab
  4. Apoplexy treatment? → IV HC 100 mg + IV NS + emergent MRI
  5. Replacement order? → Cortisol first, then T4
  6. ACTH stim cortisol cutoff? → < 18 (老) / < 14 (新)
  7. Acute (< 4 wk) post-pituitary surgery ACTH stim? → False negative
  8. Central hypothyroid monitor? → Free T4
  9. Secondary AI hyperpigmentation? → No (ACTH not high)
  10. Secondary AI hyperK? → Mild only (aldo via RAS)
  11. Stress dose surgery? → 100 mg HC IV q6h × 24h
  12. TBI screen? → 6-12 mo post
  13. Empty sella? → Sheehan, primary, IIH, post-surgery
  14. Macimorelin? → Oral GH stim
  15. PROP1 def? → GH/PRL/TSH/LH/FSH ± ACTH

⚠ AI 草皿。