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Flashcards in Endocrinology Deck (154):
1

45M
recurrent headaches past 3 months
sometimes accompanied by loss of peripheral vision (bitemporal hemianopsia)
notes that neither his hat nor gloves fit properly anymore
BP 150/90
CXR = heart enlargement

Diagnosis?

Acromegaly

(differentiate from Gigantism!)

2

Acromegaly:
Underlying cause?

pituitary tumor secreting excess amounts of growth hormone

3

Acromegaly:
Important thing to do?

compare current appearance with old photos to see difference in facial features (coarsening of appearance)

4

Acromegaly:
Why loss of peripheral vision?

pituitary tumor is compressing the optic chiasm, causing bitemporal hemianopsia

5

Acromegaly:
Why prone to carpal tunnel syndrome?

bone overgrowth compresses median nerve

6

Acromegaly:
best initial test?

serum IGF-1 levels (insulin like growth factor-1)

note that GH is unreliable because it responds to may stimuli

7

Acromegaly:
best confirmatory test?

serum GH aftern an OGTT (glucose normally suppresses GH) --> if not = ectopic GH

note that GH increases in hypoglycemia

8

Acromegaly:
What is the most appropriate management?

transsphenoidal resection of tumor

9

Acromegaly:
Drug given preoperatively to shrink size of tumor?

Octreotide (somatostatin analogue)

10

44F
no period for the last 8 months
PT negative
daily headaches, changes in vision, milky breast discharge

Diagnosis?

Prolactinoma

Note that "changes in vision" probably is bitemporal hemianopsia

Note: nonfunctional tumors, adenoma MENI

11

Prolactinoma:
underlying cause?

pituitary tumor secreting excess amounts of prolactin

12

Prolactinoma:
why amenorrhea?

PRL inhibits GnRH --> decreased GnRH = decreased FSH and LH = interruption of menstrual cycle

13

Prolactinoma:
what are the physiologic downregulators of prolactin secretion?

Dopamine!!!
Estrogen
Progesterone
Somatostatin

Correlate with schizophrenia

14

Prolactinoma:
best initial management?

drug therapy with bromocriptine or cabergoline (dopamine agonists)

Careful! may cause Erythromelalgai --- painful fingers

15

Prolactinoma:
What drugs are known to cause secondary hyperprolactinemia?

Metoclopramide
Amitryptiline
Phenothiazines
Antipsychotics

16

62M
generalized seizures
recently diagnosed with lung cancer
decreased serum sodium levels
CT scan = cerebral edema

Diagnosis?

SIADH

17

SIADH:
underlying cause?

may be due to lung cancer composed of neuroendocrine cells --- causing autonomous production of excess ADH (small cell or oat cell lung cancer)

18

ADH
source?
site of action?
function?

posterior pituitary
medullary collecting duct
increases water permeability through aquaporins
(DCT, CCT)

19

Aldosterone
source?
site of action?
function?

adrenal cortex (zona glomerulosa)
cortical collecting duct
sodium reabsorption and potassium secretion

20

SIADH:
why a decrease in Na?

increased water retention causes dilutional hyponatremia

note: urine sodium >500 in SIADH
massive water in urine = dilute = DI

21

SIADH:
why seizures?

decreased sodium creates an osmotic gradient causing water movement into the brain, causing cerebral edema

22

SIADH:
treatment?

asymptomatic hyponatremia = water deprivation
if with seizures = correct with saline, water deprivation --> Demeclocycline

23

39F
Anterior neck mass
Weight loss
Excess sweating
Increased bowel movements
Irregular menses
PE BP130/80, HR112, RR 16
Fine finger tremors
Mild exophthalmos

Diagnosis?

Hyperthyroidism (Graves' Disease)

Note that opthalmopathy is specify to Graves

24

Hyperthyroidism:
Underlying cause?

Autoantibodies stimulate hypersecretion of thyroid hormones

25

Hyperthyroidism:
What autoantibodies are present?

Anti-TSH receptor antibodies

26

Hyperthyroidism:
What drugs can cause a similar condition?

Amiodarone (hyper and hypo)
Clofibrate
Methadone

27

Hyperthyroidism:
DOC?
Feared side effect

Thionamides --- PTU, MM

Agranulocytosis --- clinically significant decrease in WBC with clinical signs and symptoms (200 to 300)

28

Hyperthyroidism:
What is the most appropriate diagnostic test?
Expected results?

Free T4 (increased)
TSH (decreased)

29

Hyperthyroidism:
Most appropriate treatment?

Radioactive iodine ablation therapy

30

Hyperthyroidism:
Expected treatment complication?

Secondary hypothyroidism

31

Hyperthyroidism:
If surgical intervention is contemplated, what drug should be given preoperatively?

Iodides to decrease gland vascularity

32

Hyperthyroidism:
Picture of primary hyperthyroidism?

TRH decreased
TSH decreased
T4 increased

33

Hyperthyroidism:
Picture of secondary hyperthyroidism?

TRH decreased
TSH increased
T4 increased

34

Hyperthyroidism:
Picture of tertiary hyperthyroidism?

TRH increased
TSH increased
T4 increased

35

Hyperthyroidism:
Why weight loss?

Excess T3 T4 causes increased catabolism

36

Hyperthyroidism:
Excess sweating? Increased BM? Tachycardia?

Excess T3 T4 causes increased sympathetic overactivity

37

Hyperthyroidism:
Exophthalmos?

Increased volume of retrobulbar tissue due to deposition of GAGs as a result of lymphocytic infiltration

38

Hyperthyroidism:
Fine finger tremors?

Excess T3 T4, causing increased synaptic transmission and increased cerebration, leading to reflex oscillation of muscle fibers

39

Hyperthyroidism:
Irregular menses?

Excess T3 T4
Increased SHBG levels
Increased total serum estrogen
Resulting in increased LH and decreasing mid cycle LH surge

40

45F
Fatigue, depression, mild weight gain
Amenorrhea
Pregnancy test negative
Heart rate 58
Coarse dry skin
Bilateral eyelid edema

Diagnosis?

Hypothyroidism

(MC worldwide is Hashimoto's thyroiditis)
(Endemic areas: goitrogens = in iodine)

41

Hypothyroidism:
Underlying cause?

Antibodies against thyroglobulin and thyroid peroxidase lead to autoimmune destruction of the thyroid gland

42

Hypothyroidism:
Primary hypothyroidism?

TRH increased
TSH increased
T4 decreased

43

Hypothyroidism:
Secondary hypothyroidism?

TRH increased
TSH decreased
T4 decreased

44

Hypothyroidism:
Tertiary hypothyroidism?

TRH decreased
TSH decreased
T4 decreased

45

Hypothyroidism:
Fatigue and weight gain?

Low t3 t4 causes decreased metabolism

46

Hypothyroidism:
Bradycardia?

Low t3 t4 decreases sympathetic drive

47

Hypothyroidism:
Coarse dry skin?

Low t3 t4 causes decreased heat production and decreased sweating

48

Hypothyroidism:
Depression?

Low t3 t4 causes decreased synaptic transmission in the brain, and decreased production of neurotransmitters --- serotonin

49

Hypothyroidism:
Amenorrhea?

Low t3 t4 causes increase in TRH, leading to increased PRL (same alpha subunit), decrease GnRH, decreased FSH and LH

50

Hypothyroidism:
Bilateral eyelid edema?

Deposition of GAGs as a result of lymphocytic infiltration of the connective tissue of the skin

51

45F
Underwent total thyroidectomy for thyroid cancer
Ten hours after the operation, she complains of twitching around her mouth, hands, and feet

Diagnosis?

Hypoparathyroidism

52

Hypoparathyroidism:
Cause?

Inadvertent removal of the parathyroid glands during thyroid surgery

53

Hypoparathyroidism:
Muscle twitching?

Low serum calcium increases excitability of motor neurons by decreasing the threshold potential (hypocalcemic tetany)

54

Hypoparathyroidism:
Primary hypothyroidism?

PTH decreased
Serum Ca decreased
Serum PO4 increased

55

Hypoparathyroidism:
Secondary parahypothyroidism?

End organ resistance to PTH
Aka pseudo hypoparathyroidism (PPH too)
PTH decreased (increased)
Ca decreased
PO4 increased

56

40F
extreme fatigue
history of kidney stones
depressed
weight loss
muscle weakness
increased serum calcium

Diagnosis?

Hyperparathyroidism

57

Most common cause of hypercalcemia

Hyperparathyroidism

58

Most common cause of hyperparathyroidism

Parathyroid adenoma

59

Hyperparathyroidism:
underlying cause?

parathyroid tumor secreting large amounts of PTH into the bloodstream

causes increased resorption of bone --- osteoclasts

60

Hyperparathyroidism:
primary hyperparathyroidism?

PTH increased
serum Ca increased
serum PO4 decreased

61

Hyperparathyroidism:
secondary hyperparathyroidism

PTH increased
serum Ca decreased
serum PO4 decreased

62

Hyperparathyroidism:
MCC of secondary hyperparathyroidism = ___ causing decreased ___

renal failure
serum calcium

63

Hyperparathyroidism:
Is there such as tertiary hyperparathyroidism?

Yes --- corrected source of hypocalcemia but increased PTH (hyperplasia), decreased calcium

64

Hyperparathyroidism:
depression and fatigue?

mechanism unknown

65

Hyperparathyroidism:
kidney stones?

due to increased urinary calcium concentration

66

Hyperparathyroidism:
muscle weakness?

excess PTH causes increased protein breakdown and muscular atrophy

67

Hyperparathyroidism:
other expected symptoms?

painful bones, renal stones, abdominal groans, psychic overtones

68

Hyperparathyroidism:
most appropriate treatment?

surgical parathyroidectomy

69

Hyperparathyroidism:
Surgical parathyroidectomy---?

remove 3.5 and put 0.5 on the forearm (or SCM)

70

Hyperparathyroidism:
what structure may be injured during surgical treatment of this condition?

recurrent laryngeal nerve

71

Hyperparathyroidism:
what malignancy may present similarly?

hypercalcemia of malignancy (usually SCCA of the lungs) due to production of PTH

72

MCC of hypoparathyroidsm?

iatrogenic

73

If patient presents with hypercalcemia, what test is most useful in helping you determine what's going on?

PTH

74

Hyperparathyroidism:
What other diseases can result in secondary forms of this condition?

chronic kidney disease
chronic pancreatitis
malabsorption

75

7M
new onset bed wetting and weight loss
eating and drinking more than usual but continues to lose weight
PE normal
labs reveal increased fasting blood glucose levels
urine glucose elevated

Diagnosis?

diabetes mellitus type I

76

Diabetes Mellitus Type I:
underlying cause?

autoimmune destruction of beta cells in the pancreas, leading to insulin deficiency

77

Diabetes Mellitus:
Actions of Insulin --- predict effect on blood level
Increases glucose uptake into cells ---
Increases glycogen formation ---
Decreases glycogenolysis ---
Decreases gluconeogenesis ---
Increases protein synthesis ---
Increases fat deposition ---
Decreases lipolysis ---
Increases K uptake into cells ---

Decreased glucose
Decreased glucose
Decreased glucose
Decreased glucose
Decreased amino acids
Decreased fatty acids
Decreased ketoacids
Decreased potassium

78

Diabetes Mellitus:
Type 1 Diabetes
Glucose?
Insulin?
C-peptide?

increased
decreased
decreased

79

Diabetes Mellitus:
Type 2 Diabetes
Glucose?
Insulin?
C-peptide?

increased
increased/normal
increased/normal

80

Diabetes Mellitus Type I:
bedwetting?

due to osmotic diuretic effect of glucose

81

Diabetes Mellitus Type I:
why increased urinary glucose?

transport maxima for glucose has been exceeded

82

Diabetes Mellitus Type I:
weight loss?

decreased insulin causes increased protein degradation and muscle wasting

83

Diabetes Mellitus Type I:
polydipsia?

increased thirst as a response to frequent urination

84

Diabetes Mellitus Type I:
polyphagia?

decreased uptake of glucose into target cells in the body triggers excessive hunger

85

Diabetes Mellitus Type I:
explanation for a delayed age of presentation?

residual beta cell function aka honeymoon period ("okay then not")

86

Diabetes Mellitus Type I:
most appropriate treatment?

insulin regimen
glucose monitoring

87

Diabetes Mellitus Type I:
diagnostic tests?

RBC with ssx >200
FBS >126
2h 75g OGTT >200
HbA1C >6.5

88

Diabetes Mellitus Type I:
complications expected if left untreated?

basement membrane thickening
arteriolar glomerulosclerosis

acute setting: diabetic ketoacidosis
chronic complications: macro/microvascular, neuropathy, cataracts, nephropathy

89

Diabetes Mellitus Type I:
considerations if child develops early morning hyperglycemia?

Somogyi effect
Dawn phenomenon
Waning of insulin dose

90

Diabetes Mellitus Type I:
Differentiate:
Somogyi effect
Dawn phenomenon
Waning of insulin dose

Somogyi effect: too much insulin at bedtime
(Somobra Insulin Effect, hypoglycemia at 3AM, hyperglycemia at 7AM)

Dawn phenomenon: some hyperglycemia at 4AM to 5AM, due to GH secretion at these times, normal effect; but by 7AM, hyperglycemia (check notes in patho pearls)

Waning of insulin dose: 3AM = hyperglycemia already
(Wala na Insulin = underdose)

check table in your handout, page 36

91

Diabetes Mellitus Type I:
pathognomonic triad of DKA?
pathogenesis?
labs to be requested immediately?
responsible for fruity breath?
factors that can incite this condition? 5Is
most appropriate treatment?

hyperglycemia
ketonemia
HAGMA

uncontrolled hyperglycemia causes ketoacidosis

urine ketones
ABG
serum glucose

ketone bodies: acetoacetate and beta hydroxybutyrate

5Is: infection, ischemia, infarction, ignorance, intoxication

fluid replacement (IV NSS bolus) plus insulin drip
(MUST CORRECT POTASSIUM FIRST!)

92

Diabetes Mellitus Type I:
responsible for fruity breath in DKA?

ketone bodies (acetoacetate and beta hydroxybutyrate)

93

32M
headaches 1 week duration
sweats much more than he used to
trembling
tachycardic
BP 220/160
abdomen soft and nontender
CT scan = adrenal mass

Diagnosis?

Pheochromocytoma

(versus neuroblastoma)

94

Pheochromocytoma:
underlying cause?

excess catecholamine production from neoplastic chromaffin cells in the adrenal medulla

95

Pheochromocytoma:
headaches?

due to increased blood pressure

96

Pheochromocytoma:
diaphoressis, tremors, tachycardia, hypertension?

due to excessive activation of the symphathetic nervous system asa result of excess catecholamines in circulation

97

Pheochromocytoma:
classic triad?

tachycardia, sweating, headaches

98

Pheochromocytoma:
most appropriate diagnostic test?

urine vanillylmandelic acid (urine metaphrines)

99

Pheochromocytoma:
most appropriate imaging study?

abdominal CT scan

100

Pheochromocytoma:
most appropriate treatment?

surgical resection --- must suppress pharmacologically first!

HOW?
phenoxybenzamine
phentolamine
labetalol

101

Pheochromocytoma:
What drugs should the patient receive prior to surgical intervention?

phenoxybenzamine
phentolamine
labetalol

102

Pheochromocytoma:
What cancer syndromes are associated with this condition?

multiple endocrine neoplasia (MEN)
MEN IIa: PCC, medullary thyroid CA, PTH
MEN IIb: PCC, medullary thyroid CA, neuromas

103

Pheochromocytoma:
describe the rule of 10s

10% bilateral
10% extra-adrenal
10% malignant
10% familial
10% pediatric
10% without blood pressure elevation

104

41F
persisten hyptertension unresponsive to medicaitons
fatigue
muscle weakness
polyuria
edema absent
blood test = metabolic alkalosis, low potassium, and high sodium levels
CT scan = adrenal mass

Diagnosis?

Conn Syndrome (primary hyperaldosteronism)

105

Conn Syndrome (primary hyperaldosteronism):
underlying cause?

excess aldosterone production from an adrenal cortex tumor

106

Conn Syndrome (primary hyperaldosteronism):
persistent hypertension?

due to excess aldosterone production

107

Conn Syndrome (primary hyperaldosteronism):
normal sodium excretion and no edema despite increased ECF volume?

due to the SODIUM ESCAPE PHENOMENON (increased BP causes increased production of ANP, normalizing Na excretion and preventing development of edema) --- increased pressure on th heart

108

Conn Syndrome (primary hyperaldosteronism):
Why fatigue and muscle weakness?

due to decreased potassium levels

109

Conn Syndrome (primary hyperaldosteronism):
polyuria?

decreased potassium impairs urine concentrating ability (countercurrent multiplier uses Na-K-2Cl co transport)

110

Conn Syndrome (primary hyperaldosteronism):
metabolic alkalosis?

hydrogen ion loss into the urine and migration into potassium depleted cells

potassium deficiency increases the capacity of the proximal convoluted tubule to reabsorb filtered bicarbonate --- px: type II renal tubular acidosis

111

Conn Syndrome (primary hyperaldosteronism):
most appropriate treatment?

surgical removal of adrenal mass

112

Conn Syndrome (primary hyperaldosteronism):
management for unresectable tumors?

aldosterone antagonists (spironolactone, eplerenone)

113

36F
hypertension, easy bruising, hirsutism, amenorrhea, acne
PE: central obesity, proximal weakness, edema and violaceous abdominal striae
CT scan = adrenal mass

Cushing Syndrome (primary hypercotisolism)

114

Cushing Syndrome (primary hypercotisolism):
cause?

excess cortisol production from an adrenal cortex tumor

115

Cushing Syndrome (primary hypercotisolism):
most common cause of Cushing symdrome?

iatrogenic --- excess steroid intake

116

Primary hyperaldosteronism versus Secondary hyperaldosteronism
Aldosterone?

PH: increased
SH: increased

117

Primary hyperaldosteronism versus Secondary hyperaldosteronism
Renin?

PH: decreased (hyporenin)
SH: increased

118

Primary hyperaldosteronism versus Secondary hyperaldosteronism
ECF volume>

PH: increased
SH: increased

119

Primary hyperaldosteronism versus Secondary hyperaldosteronism
Na excretion?

PH: no change
SH: decreased

120

Primary hyperaldosteronism versus Secondary hyperaldosteronism
edema?

PH: absent
SH: present

121

Primary hyperaldosteronism versus Secondary hyperaldosteronism
etiology?

PH: Conn Syndrome (adrenal tumor)
plasma renin versus serum aldosterone

SH: Renin-secreting tumor, Renal artery stenosis

122

Cushing Syndrome (primary hypercotisolism):
hypertension?

excess cortisol increases vascular responsiveness to catecholamines, leading to increased total peripheral resistance

at high doses, glucocorticoids display mineralocorticoid effects, leading to salt and water retention

123

Cushing Syndrome (primary hypercotisolism):
central obesity?

catabolism of skin proteins leads to weakening and rupture of collagen fibers in the dermis

124

Cushing Syndrome (primary hypercotisolism):
easy bruising and violaceous striae?

excess cortisol leads to insulin resistance and adipose tissue deposition at charactersitic sites (moon facies, buffalo hump), skin atrophy

125

Cushing Syndrome (primary hypercotisolism):
acne and hirsutism?

due to excess adrenal androgens

excess insulin stimulates ovarian theca cells to produce androgens

126

Cushing Syndrome (primary hypercotisolism):
proximal weakness and edema?

due to excess protein catabolism and protein depletion

127

Cushing Syndrome (primary hypercotisolism):
most appropriate treatment?

surgical resection of the adrenal mass

128

Cushing Syndrome (primary hypercotisolism):
management for surgically unresectable tumors?

Ketoconazole, Metyrapone

129

Adrenal Cushing Syndrome versus
Pituitary Cushing Syndrome versus
Ectopic Cushing Syndrome

Cortisol?

Adrenal Cushing Syndrome: increased
Pituitary Cushing Syndrome: increased
Ectopic Cushing Syndrome: increased

130

Adrenal Cushing Syndrome versus
Pituitary Cushing Syndrome versus
Ectopic Cushing Syndrome

ACTH?

Adrenal Cushing Syndrome: decreased
Pituitary Cushing Syndrome: increased
Ectopic Cushing Syndrome: increased

131

Adrenal Cushing Syndrome versus
Pituitary Cushing Syndrome versus
Ectopic Cushing Syndrome

High dose dexamethasone suppression?

Adrenal Cushing Syndrome: no effect
Pituitary Cushing Syndrome: suppressed
Ectopic Cushing Syndrome: no effect

132

Adrenal Cushing Syndrome versus
Pituitary Cushing Syndrome versus
Ectopic Cushing Syndrome

etiology?

Adrenal Cushing Syndrome: cortisol producing adrenal tumor
Pituitary Cushing Syndrome: ACTH producing pituitary tumor
Ectopic Cushing Syndrome: ACTH producing lung tumor

133

22F
one month history of muscle weakness
decreased appetite
weight loss
skin darkening
orthostatic hypotension
decreased pubic hair
low sodium
high potassium
low glucose

Diagnosis?

Addison Disease

134

Addison Disease:
cause?

autoimmune destruction of adrenal glands

135

Addison Disease:
muscle weakness, weight loss and anorexia?

decreased energy mobilization due to decreased cortisol

136

Addison Disease:
skin darkening?

increased ACTH secretion leadst ot excess POMC derived hormones --- alpha-MSH, beta-MSH

137

Addison Disease:
orthostatic hypotension?

decreased aldosterone causes decreased responsiveness of the RAA

138

Addison Disease:
decreased sodium and increased potassium?

due to decreased aldosterone activity

139

Addison Disease:
decreased glucose?

decreased cortisol causes increased insulin sensitivity

140

Addison Disease:
decreased pubic hair?

due to adrenal androgen deficiency

141

Addison Disease:
signs of androgen deficiency more commonly seen in females?

adrenals are the main source of androgens in females (vs testis of males)

142

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

CRH?

Primary adrenal insufficiency: increased
Secondary adrenal insufficiency: increased
tertiary adrenal insufficiency: decreased

143

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

ACTH?

Primary adrenal insufficiency: increased
Secondary adrenal insufficiency: decreased
tertiary adrenal insufficiency: decreased

144

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

Cortisol?

Primary adrenal insufficiency: decreased
Secondary adrenal insufficiency: decreased
tertiary adrenal insufficiency: decreased

145

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

Aldosterone?

Primary adrenal insufficiency: decreased
Secondary adrenal insufficiency: normal
tertiary adrenal insufficiency: normal

146

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

Androgens?

Primary adrenal insufficiency: decreased
Secondary adrenal insufficiency: decreased
tertiary adrenal insufficiency: decreased

147

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

Hypotension?

Primary adrenal insufficiency: present
Secondary adrenal insufficiency: absent
tertiary adrenal insufficiency: absent

148

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

Skin color?

Primary adrenal insufficiency: dark (pathway shunted)
Secondary adrenal insufficiency: pale
tertiary adrenal insufficiency: pale

149

Primary adrenal insufficiency versus
Secondary adrenal insufficiency versus
tertiary adrenal insufficiency

Etiology?

Primary adrenal insufficiency: autoimmune adrenalitis
Secondary adrenal insufficiency: pituitary NOT secreting ACTH
tertiary adrenal insufficiency: steroid withdrawal

150

Addison Disease:
what is adrenal crisis?

occurrence of severe hypotension (shock) as a result of extreme adrenal hormone deficiency (usually in patients with depressed HPA axis)

151

Addison Disease:
if adrenal crisis occurred in the setting of fulminant meningococcemia, what will you consider?

Waterhouse-Friderichsen Syndrome (due to bilateral adrenal hemorrhage) --- sacs of clotted blood in the adrenals

152

Addison Disease:
most appropriate diagnostic test?

ACTH stimulation test (cosyntropin test)

153

Addison Disease:
interpretation of ACTH stimulation test aka ___

low cortisol + high ACTH = ___
high cortisol + high ACTH = ___

Cosyntropin test

Primary aldosteronism
Secondary or tertiary aldosteronism

154

Addison Disease:
most appropriate treatment?

glucocorticoid and mineralocorticoid replacement, aggressive hydration