Class 2: Endocrine Disorders

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hyperthyroidism s/s
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intolerance to heat, fine-straight hair, bulging eyes, facial flushing, enlarged thyroid, tachycardia, atrial fibrilation, increased SBP, gynecomastia, weight loss, muscle wasting, menstrual changes (amenorrhea), localized edema, increased diarrhea, tremors, finger clubbing, increased tissue sensitivity to stimulation by SNS, increased metabolism, insomnia, mood swings, delirium, inability to concentrate, decreased libido, increased sensitivity to stimulant drugs
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hypothyroidism s/s
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intolerance to cold, receding hairline, facial & eyelid edema, dull-blank expression, extreme fatigue, decreased appetite, thick tongue-slow speech, anorexia, brittle nails & hair, menstrual disturbances, hair loss, apathy, lethargy, dyspnea, dry skin (coarse & scaly) muscle weakness, constipation, subnormal temp, bradycardia, weight gain, decreased LOC, thickened skin, cardiac complications, anemia, increased sensitivity to analgesic opioids, increased susceptibility to infection
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Cushing’s Syndrome s/s
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personality changes, hyperglycemia, moon face, CNS irritability, increased susceptibility to infection, Na & fluid retention, gynecomastia (males), thin extremities, fat deposits on back, GI distress, increased acidemia, amenorrhea & hirsutism (females), thin skin, purple striae, bruises & petichiae, osteoporosis, fatty hump between shoulders
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Addison’s Disease s/s
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bronze pigmentation of skin, changes in distribution of body hair, hypoglycemia, GI disturbances, wieght loss, weakness
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Addisonian/Adrenal Crisis s/s
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profound fatigue, dehydration, vascular collapse, renal shutdown, decreased serum Na, increased serum K
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osmolality formula
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2Na + K + BUN/3 + Glucose/20
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Hyperpituitarism
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An excessive secretion of pituitary hormones (i.e. GH, ACTH, TSH, LH)
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Acromegaly
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Gradual enlargement of bony and soft tissues (bones of the face, jaw, hands, feet, and skull) causes by excessive growth hormone (GH). Occurs in adults.
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Gigantism
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Overgrowth of the long bones due to excessive growth hormone. Occurs in childhood before the closure of the epiphyseal plates.
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complications of Acromegaly
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Enlarged tongue leads to hoarseness, speech difficulties, sleep apnea. Vocal cord thickening & upper airway obstruction lead to sleep apnea, snoring GH mobilizes stored fat for energy leading to increased risk for atherosclerosis. GH is an insulin antagonist leading to hyperglycemia.
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diagnostic tests for Acromegaly
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-increased IGF-I levels (w/ GH excess) -Head CT scan/ MRI showing pituitary tumor -Skeletal x-rays -Ophthalmic exam
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assessing for Acromegaly
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-evaluate growth & development of children -question adults about increases in hat, ring, glove & shoe size -assess for s/s of diabetes mellitus -assess for cardiovascular s/s: angina, HTN, CHF
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treatment for Acromegaly
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-octreotide -radiation -transsphenoidal hypophysectomy
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complications of transsphenoidal hypophysectomy
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increased ICP, CSF leak, meningitis, transient, diabetes insipidus, hypopituitarism
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pre-op transsphenoidal hypophysectomy
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-bacitracin nose gtts, pain control, hormone replacement -teach mouth breathing, mouth care -teach to avoid valsalva maneuver, coughig, sneezing, straining
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post-op transsphenoidal hypophysectomy
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monitor for increased ICP and treat accordingly, monitor for CSF leak, mouth care q 4 hr – rinses only (no tooth brushing for 10 days), neuro checks, daily chemistry profile (including serum Na), monitor for signs of hypopituitarism, analgesics, IV antibiotic, Decadron, Strict I&O, daily weights
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Antidiuretic Hormone (Vasopressin)
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Hormone that regulates water balance. Increased secretion leads to increased water reabsorption from renal tubules leading to water conservation and decreased urinary output. This hormone is also a potent vasoconstrictor.
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Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
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Too much ADH resulting in water retention, hyponaturemia and low serum osmolality, increased in urine Na, specific gravity, and osmolality. The most common cause is small cell lung cancer.
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SIADH s/s
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decreased urine output, increased urine specific gravity, increased intravascular fluid volume, weight gain, dyspnea on exercition (DOE) & fatigue, muscle cramps & weakness d/t hyponatremia, increased cerebral edema leading to lethargy, anorexia, confusion, headache, seizure, coma and death
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nursing management for SIADH
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ID patient’s at risk, treat underlying disorder, I&O, daily weights, monitor neuro status/seizure prec., monitor labs: Na, osmolality, urine specific gravity, fluid restriction 800 – 1000mL/d, decrease thirst: ice chips, sugarless gum especially if FR is 500/day, Lasix IV, 3 – 5% hypertonic saline IV
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demeclocycline (Declomycin)
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Medication that blocks the action of ADH. Used for chronic SIADH. May induce Diabetes Insipidus (polyuria, polydipsia, weakness).
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Diabetes Insipidus
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Posterior pituitary disorder caused by an insufficiency of or resistance to ADH resulting in water loss, increased serum Na, increased serum osmalality , decreased urine Na. May be transient or life-long. May be the result of injury to the posterior pituitary, tumor of the pituitary or hypothalamus, CNS infection, Lithium drug toxicity, or psychological disorders involving excessive water consumption.
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Diabetes Insipidus s/s
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severe polyuria (5 – 20L/day), dilute urine, nocturia, enuresis, polydipsia, craving cold water, fatigue, irritability, weakness, weight loss, dehydration, constipation
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diagnostic tests for DI
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-UA: decreased osmolality & spec gravity of urine -increased serum Na & osmolality -CT/MRI -CMP (*renal function) -psychological evaluation
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nursing management for DI
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ID patients at risk, identify & treat underlying cause, monitor I&O, VS, daily weight; assess for dehydration; fluid replacement: IV or oral; monitor lab work; administer meds
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treatment for DI
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-Vasopressin: SC, IM or IV or desmopressin acetate (DDAVP) intranasal or SC -Indocin: increases responsiveness of ADH -Thiazide diuretics
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Iodine
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Chemical used by the thyroid gland to synthesize Triiodothyronine (T3) and Thyroxine (T4). May be given in large doses to inhibit synthesis of T3 and T4 and block their release into circulation. In large doses, this can decrease vascularity of thyroid gland. Solutions include saturated solution of Potassium Iodine (SSKI) and Lugol’s solution.
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Grave’s disease
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An autoimmune disorder that leads to overactivity of the thyroid gland (hyperthyroidism).
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diagnostic tests for Hyperthyroidism
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-Opthalmologic examination -ECG -TSH -free thyroxine (T4) -Total T3 & T4 -Radioactive iodine uptake (RAIU)
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Antithyroid medications
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PTU (Propylthiouracil) & methimazole (Tapazole). Therapy for 6 to 15 months with improvement seen in 1 – 2 weeks. Good results in 4 – 8 weeks.
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treatment for Hyperthyroidism
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-Antithyroid medications -Radioactive iodine therapy (RAI) -Subtotal thyroidectomy -Iodine -Beta blockers
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Radioactive Iodine Therapy (RAI)
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First choice hyperthyroidism treatment in non-pregnant adults. Destroys thyroid tissue. Takes 2 to 3 months. Antithyroid drugs and Inderal while waiting for the drug to be effective.
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nursing management for hyperthyroidism
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-Nutritional therapy: high-calorie diet (4,000 – 5,000 cal/day) for hunger and prevention of tissue breakdown; protein allowance of 1 to 2 g/kg ideal body weight; avoid caffeine, highly seasoned foods, and high-fiber foods; vitamins -Monitor for cardiac dysrhythmias -Keep pt calm, cool and quiet room -Light bed coverings (heat intolerance) -Change linens frequently if diaphoretic -Eye care: Apply artificial tears to relieve eye discomfort; Tape eyelids shut for sleep if they cannot close; Dark glasses to reduce glare and prevent environmental irritants
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post-op thyroidectomy
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Every 2 hours for 24 hours assess for signs of hemorrhage (fullness at site) and assess for tracheal compression (irregular breathing, neck swelling, frequent swallowing, choking) Position patient in Semi-Fowler’s position and support the head with pillows to avoid flexion of neck and tension on suture lines. Check for signs of hypocalcemia such as tetany, Trousseau’s sign, and Chvostek’s sign. Some hoarseness for 3 to 4 days is expected. Patient is initially restricted to clear liquids. Have a tracheotomy tray and suction ready at bedside.
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discharge teaching post-thyroidectomy
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Monitor hormone balance periodically. Total thyroidectomys require lifelong therapy. Decrease caloric intake to prevent wieght gain. Adequate iodine intake is a priority. No radiation safety precautions are necessary for radioactive iodine therpay.
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Thyrotoxicosis (Thyroid crisis, thyroid storm)
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Acute condition where all manifestations of hyperthyroidism are heightened. Death rare when treatment initiated. Presumed causes are additional stressors.
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treatment for Thyrotoxic crisis
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-Decrease thyroid hormone levels and clinical manifestations with drug therapy. -Manage respiratory distress, fever reduction, fluid replacement, and manage stressors.
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Hypothyroidism
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Thyroid hormone deficiency leading to slowing of the metabolic process. The most common cause worldwide is Iodine deficiency. Atrophy of the thyroid gland and overtreatment of hyperthyroidism are other, less common, causes.
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diagnostic tests for Hypothyroidism
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-Decreased T3, T4, and RBC levels. -TSH: decreased if pituitary disease or increased if thyroid disease -Increased cholesterol -Anemia -CT/MRI -ECG (bradycardia)
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levothyronine (Synthroid)
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Drug used for thyroid hormone replacement. Dosage measured in mcg. Monitor cardiac function when administering this medication especially to the elderly. This drug increases the effects of anticoagulants and decreases the effects of insulin, oral hypoglycemics, and Digoxin
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myxedema coma
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Life threatening complication of hypothyroidism due to persistently low thyroid hormone levels. May be triggered by sedatives, infection, or other stress on the body. Signs and symptoms include hypothermia, respiratory depression, hypoventilation, bradycardia, hypotension, cardiovascular collapse, decreased LOC, and coma. Treatment includes respiratory and cardiac support, IV thyroid hormone replacement, IV fluids and electrolytes.
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nursing management for myxedema coma
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Monitor cardiopulmonary, neurologic and renal function. Warm the patient’s body gradually (not quickly) to avoid quick vasodilation resulting in a rapid drop in BP.
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glucocorticoids, mineralocorticoids, androgens
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The three types of hormones produced by the adrenal cortex categorized as corticosteroids. These steroids affect the 3 S’s (Sugar, Salt, Sex)
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catecholamines
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The category of hormones produced in the adrenal medulla which includes epinephrine and norepinephrine.
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Cushing’s syndrome
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A rare endocrine disorder caused by chronic exposure of the body’s tissues to exogenous or endogenous excess cortisol (glucocorticoids, mineral corticoids; Sugar, Salt). Most commonly caused by a pituitary gland tumor secreting too much adrenocorticotropic hormone (ACTH). May also be caused by prolonged administration of glucocorticoid medications.
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Adrenocortical Insufficiency
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Lack of some or all adrenal corticosteroids. This caused by either destruction of the adrenal glands or underproduction of hormones in the adrenal cortex.
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Addison’s disease
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Underproduction of hormones in the adrenal cortex.
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treatment for Cushing’s syndrome
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-Surgery: Transphenoidal hypophysectomy or adrenalectomy (depends on the underlying cause) -Radiation -Medication to suppress cortisol production (ketoconazole, aminoglutethimide)
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discharge teaching for adrenocorticoid insufficiency/excess
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Lifelong hormone replacement therapy (for insufficiency) Medic alert bracelet Never stop corticosteroids abruptly Alternate day therapy Dose may be increased during periods of stress Diurnal (daytime) pattern for administration
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Addisonian/Adrenal crisis
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An acute life threatening condition characterized by extremely low levels of adrenocortical hormone. Caused by an abrupt cessation of adrenocorticotropic meds and/or increased stress, illness, surgery, dehydration. Exaggerated symptoms of adrenal insufficiency coupled with signs of shock (hypotension, rapid, weak pulse, rapid respirations, pallor, weakness)
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treatment for Addisonian/Adrenal crisis
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-Treat hypovolemic shock: fluids, vasopressors, position in Trendelenburg’s position -Monitor and replace blood glucose, electrolytes (Na+) -Steroid replacement: IV hydrocortisone -Avoid stressors
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pheochromocytoma
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An adrenal medulla tumor which causes an overproduction of the catecholamines epinephrine and norepinephrine. 95% are benign or encapsulated. Causes overstimulation of the sympathetic nervous system.
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pheochromocytoma s/s
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Severe, episodic HTN, severe pounding headache, tachycardia, palpitations, diaphoresis, chest pain
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diagnostic tests for pheochromocytoma
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-Plasma catecholamines -Urine: catecholamine metabolites -CT/MRI/US to localize tumor -Clonidine (alpha2-agonist) suppression test
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treatment for pheochromocytoma
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-Alpha adrenergic blockers to lower BP -Beta blockers to lower BP -Mitotane (Lysodren) -Adrenalectomy
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pre-op Adrenalectomy
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-Monitor VS, CP status -IV corticosteroids pre-op -raise HOB -monitor fluid and electrolytes -administer medications to reduce BP
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post-op Adrenalectomy
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-Basic post-op care as for any abdominal surgery -Monitor BP, blood glucose levels closely -Administer hydrocortisone
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PTU (Propylthiouracil), methimazole (Tapazole)
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Two common Antithyroid medications
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octreotide
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Medication used to treat Acromegaly.
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aminoglutethimide, ketoconazole
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2 medications commonly used to treat Cushing’s syndrome

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