399.2 📚 國考版醫垫國考 / PGY OSCE

399.2.0.1 📌 Cram Sheet

399.2.0.1.1 🔥 高 yield 18
  1. 3 zones GFR: G(salt) F(sugar) R(sex)
  2. Cushing’s screen 3: 1mg dex / 24h urine / late-night salivary (≥ 2)
  3. Cushing’s localize: ACTH → high-dose dex → CRH stim → IPSS gold
  4. Iatrogenic Cushing’s = 最垞芋 cause overall
  5. AI primary vs central: ACTH high (primary, hyperpig) vs low/normal (central, no pig)
  6. Primary AI 特異: hyperpigmentation, hyperK, salt-wasting (aldo deficient)
  7. Cosyntropin stim < 18 (老) / < 14 (新) → AI
  8. Acute (< 4 wk) post-pituitary surgery ACTH stim: false negative
  9. Adrenal crisis: HC 100 mg IV STAT + NS + treat trigger
  10. Stress dose mandatory in cortisol-deficient
  11. PA (Conn’s) = endocrine HTN #1; resistant HTN consider
  12. ARR > 30 + aldo > 15 screen; saline suppression confirm; AVS lateralize
  13. CAH 21-hydroxylase 95%; classic vs non-classic
  14. 17-OHP ↑↑ = 21-OH def
  15. CAH 兒童甚 HC (避 prednisone growth suppression)
  16. 11β-OH def → HTN + virilization
  17. 17α-OH def → HTN + sex amb
  18. Adrenal incidentaloma: < 10 HU benign; > 4-6 cm 或 functional → surgery; 必 rule out pheo + cortisol + aldo
399.2.0.1.2 🔢 必背
項目 æ•žå­—
1-mg dex cutoff < 1.8 ÎŒg/dL
24-h urine cortisol > 3-4× upper
Late-night salivary > 0.15
Cosyntropin cutoff < 18 (老) / < 14 (新)
ARR threshold > 30
Aldo threshold > 15 ng/dL
Adrenal HU benign < 10
Washout absolute > 60% (benign)
Adrenal mass surgery > 4-6 cm
HC daily replacement 15-25 mg split
Fludrocortisone 0.05-0.2 mg/d
Stress dose mild 雙倍 × 24-48h
Stress dose surgery 100 mg IV → 50 q6h
21-OH CAH % of all CAH 95%
17-OHP CAH ↑↑

399.2.0.2 ⭐ 高 yield

399.2.0.2.1 Cushing’s Causes Quick
Type %
Iatrogenic 最垞芋 overall
Cushing’s disease (pituitary) 70-80% endogenous
Ectopic ACTH (SCLC, carcinoid, MTC, pheo) ~15% endogenous
Adrenal adenoma ~10% endogenous
Adrenal CA < 5%
Macronodular hyperplasia rare
399.2.0.2.2 AI Causes Quick
Type Cause
Primary (Addison’s) Autoimmune (80%), TB, hemorrhage, metastasis, HIV, ALD, drug
Secondary Pituitary (tumor, surgery, RT, Sheehan, apoplexy, ICI)
Tertiary Long-term exogenous steroid (most common); hypothalamic
399.2.0.2.3 CAH Comparison
Enzyme Block Phenotype
21-OH aldo + cortisol blocked, androgen up Salt-wasting + virilization
11β-OH aldo blocked but DOC up; cortisol blocked, androgen up HTN + virilization
17α-OH sex steroid blocked + cortisol blocked; DOC up HTN + sex amb (no virilization)
3β-HSD aldo + cortisol + androgen all blocked Salt-wasting + ambiguous
StAR (lipoid) All blocked Severe, neonatal lethal
399.2.0.2.4 Primary Aldosteronism
  • ARR > 30 + aldo > 15 → screen positive
  • Saline / captopril / oral Na load → confirm
  • AVS for lateralization (CT alone unreliable)
  • Treatment: surgery if APA, MRA (spironolactone/eplerenone) if BAH
399.2.0.2.5 Adrenal Incidentaloma Workup
  1. Functional workup: 1mg dex, metanephrine, ARR (always)
  2. Imaging: CT HU, washout, MRI chemical shift
  3. Decision:
    • Functional → surgery

    • 4-6 cm or suspicious → surgery

    • < 10 HU + non-functional → f/u 6-12 mo
399.2.0.2.6 Cushing’s Drugs Quick
Class Drug
Steroidogenesis inhibitor Ketoconazole, metyrapone, osilodrostat, levoketoconazole, etomidate
Pituitary-directed Pasireotide LAR, cabergoline
GR antagonist Mifepristone, relacorilant
Adrenolytic Mitotane (ACC)
Last resort Bilateral adrenalectomy
399.2.0.2.7 Drug-induced AI
  • Long-term steroid → withdrawal AI
  • Ketoconazole, etomidate, mitotane (block synthesis)
  • Abiraterone (CYP17 inhibitor — prostate CA)
  • ICI hypophysitis (pembro, nivo, ipilimumab)
  • Megestrol (steroid-like, suppresses HPA)

399.2.0.3 🎯 自我檢枬

  1. 3 zones GFR? → G(salt) F(sugar) R(sex)
  2. Cushing’s screen 3? → 1mg dex / 24h urine / salivary
  3. CD vs ectopic ACTH high-dose dex? → CD suppresses
  4. IPSS central:peripheral? → > 2 basal, > 3 post-CRH
  5. AI primary feature? → Hyperpigmentation
  6. Cosyntropin cutoff? → < 18 (older) / < 14 (newer)
  7. Adrenal crisis treatment? → HC 100 mg IV + NS
  8. Stress dose surgery? → HC 100 mg IV + 50 q6h
  9. PA screen? → ARR > 30 + aldo > 15
  10. PA gold standard subtyping? → AVS
  11. CAH 21-OH lab? → 17-OHP ↑↑
  12. Pediatric CAH steroid? → HC (avoid prednisone)
  13. 11β-OH CAH BP? → HTN
  14. Adrenal HU benign? → < 10
  15. Incidentaloma workup must include? → Pheo + cortisol + aldo
  16. Mitotane indication? → ACC
  17. ALD pattern? → X-linked, very long chain FA, primary AI + neuro
  18. Nelson syndrome? → Bilateral adrenalectomy → corticotroph adenoma expand

⚠ AI 草皿。