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  • Abdomen Acute
  • Abdominal Infarction
  • Abdominal Pain
  • Abdominal Pain Chronic
  • Abdominal Pain-Lower Abdomen
  • Abdominal Pain-Upper AbdomenAbdominal
  • Absence Seizure
  • Abuse-Psychological, Physical, Or Sexual
  • Acoustic Neuroma
  • Acromegaly
  • Acute Appendicitis, Unspecified
  • Acute Intermittent Porphyria (AIP)
  • Acute Renal Failure
  • Acute Stress Disorder
  • Addison's Disease
  • ADHD Adult
  • ADHD-Sleep Disorder Related To ADHD
  • Adjustment Disorder
  • Adrenal Disease
  • Adrenal Disease-Cushing's
  • Adrenal Insufficiency-Addison's Disease
  • Adult ADHD (ADD)
  • Agoraphobia
  • AIDS-Acquired Immune Deficiency Syndrome
  • Akathisia
  • Akathisia Medication-induced
  • Alcohol Abuse
  • Alcohol Dependence
  • Alcohol Dependence In Remission
  • Alcohol Use Disorder
  • Alcohol-Flush-Aldehyde Dehydrogenase Deficiency
  • Aldehyde Dehydrogenase Deficiency
  • Alopecia Areata
  • Alopecia Secondary To Childbirth
  • Alopecia Universalis
  • Alopecia-Male Pattern Baldness
  • Alopecia-Medication-induced
  • Alopecia-Telogen Effluvium
  • Alopecia-Traction
  • Alport Syndrome
  • Aluminum Toxicity
  • Alzheimer's
  • Alzheimer's Dementia
  • Amnestic Disorder
  • Amphetamine Abuse
  • Amphetamine Dependence
  • Amphetamine Dependence In Remission
  • Amyloidosis
  • Amyotrophic Lateral Sclerosis
  • Amyotrophic Lateral Sclerosis (ALS)
  • Anemia
  • Aneurysmal Subarachnoid Hemorrhage
  • Angina Pectoris
  • Angina Unstable
  • Ankylosing Spondylitis
  • Anorexia Nervosa
  • Anorgasmia
  • Antisocial Personality Disorder
  • Anxiety Disorder
  • Anxiety Disorder Due To Another Medical Condition
  • Anxiety-Agoraphobia
  • Anxiety-Organic
  • Anxiety-PTSD (Post-traumatic Stress Disorder)
  • Anxiety-Specific Phobia
  • Aortic Aneurysm
  • Appendicitis
  • Appendicitis-Acute, Unspecified
  • Arrhythmia
  • Arsenic Toxicity
  • Arthritis
  • Arthritis-Cervical
  • Arthritis-Osteoarthritis
  • Arthritis-Rheumatoid
  • Asperger's Syndrome
  • Asthma
  • Atonic Seizure
  • Atypical Depression
  • Auditory Hallucinations
  • Auriculotemporal Nerve Syndrome
  • Autoimmune Hepatitis
  • Avitaminosis
  • Avoidant Personality Disorder
  • B12 Deficiency
  • Bacterial Preexisting Heart Conditions
  • Balance-Disequilibrium-Benign Positional Vertigo
  • Balance-Disequilibrium-Cerebellar Disease
  • Balance-Disequilibrium-Friedreich's Ataxia
  • Balance-Disequilibrium-Labyrinthitis-Acute
  • Balance-Disequilibrium-Vertigo-Central
  • Balance-Disequilibrium-Vertigo-Medication-induced
  • Balance-Disequilibrium-Vertigo-Peripheral
  • Balance-Disequilibrium-Vertigo-Toxin-induced
  • Balance-Disequilibrium-Vestibular-Neuritis
  • Balding-Alopecia Areata
  • Balding-Alopecia Secondary To Childbirth
  • Balding-Alopecia Universalis
  • Balding-Alopecia-Male Pattern
  • Balding-Alopecia-Medication-induced
  • Balding-Alopecia-Traction
  • Balding-Telogen Effluvium
  • Barbiturate -use
  • Barbiturate Abuse
  • Barbiturate Dependence
  • Benzodiazepine Abuse
  • Benzodiazepine Dependence
  • Benzodiazepine Dependence In Remission
  • Benzodiazepine Use
  • Bereavement
  • Bile Duct Obstruction
  • Binge Eating Disorder
  • Bipolar
  • Bipolar Disorder
  • Bipolar Irritability
  • Bipolar-Atypical Depression
  • Bipolar-Dissociative Disorder
  • Bipolar-Dissociative Identity Disorder
  • Bipolar-Irritability
  • Bipolar-Kleptomania
  • Bipolar-Pathological Gambling
  • Bipolar-SAD (Seasonal Affective Disorder)
  • Bladder Disorder
  • Bladder Disorder, Unspecified
  • Bladder Disorder-Unspecified
  • Bladder-Incomplete Bladder Emptying
  • Bladder-Incontinence-Unaware
  • Bladder-Incontinence-Urge Incontinence
  • Bladder-Incontinence-Urinary Stress Incontinence
  • Bladder-Urinary Urgency
  • Bleeding Disorder
  • Blood In The Urine
  • Blood-Anemia
  • Blood-Bleeding Disorder
  • Blood-Epistaxis
  • Blood-Hematemesis
  • Blood-Hematochezia
  • Blood-Hematuria
  • Blood-Hemochromatosis
  • Blood-Hemoptysis
  • Blood-Melena
  • Blood-Polycythemia
  • Blood-Sickle Cell Anemia
  • Blood-Thrombocytopenia
  • Body Dysmorphic Disorder
  • Body Fluid Change
  • Borderline Personality Disorder
  • Boron Toxicity
  • Bowel-Constipation
  • Bowel-Diarrhea
  • Bowel-Diverticulitis
  • Bowel-Diverticulosis
  • Bowel-Essential Palatal Tremor
  • Bowel-Food Allergy
  • Bowel-Gastritis
  • Bowel-Gastroenteritis
  • Bowel-Hiatal Hernia
  • Bowel-Lactase Deficiency
  • Bowel-Nutrition-Gluten-Celiac Disease
  • Bowel-Nutrition-Lactose Intolerance
  • Bowel-Nutrition-Malabsorption
  • Bowel-Nutrition-Malnutrition
  • Bowel-Nutrition-Tropical Sprue
  • Bowel-Pain-Abdomen
  • Bowel-Pain-Abdomen-Acute
  • Bowel-Pain-Abdomen-Chronic
  • Bowel-Pain-Abdomen-Infarction
  • Bowel-Pain-Abdomen-Lower
  • Bowel-Pain-Abdomen-Upper
  • Bowel-Pain-Abdomen-Visceral
  • Bowel-Pain-Abdomen-Viscus-Perforation
  • Bowel-Pain-Erosive Esophagitis
  • Bowel-Pain-Heartburn-GERD
  • Bowel-Pain-IBS
  • Bowel-Pain-Obstruction
  • Bowel-Pain-Peritonitis
  • Bowel-Pain-PUD (Peptic Ulcer Disease)
  • Bowel-Pain-Regional Enteritis
  • Bowel-Pain-Ulcer
  • Bowel-Pain-Ulcer-Gastric
  • Bowel-Pain-Ulcer-Small Intestine-Duodenal
  • Bowel-Pain-Ulcer-Zollinger-Ellison Syndrome
  • Brain Dementia-Amnestic Disorder
  • Branchial Neuralgia
  • Bronchiectasis
  • Bronchitis
  • Bruxism (teeth Grinding)
  • Bulimia
  • Caffeine Dependence
  • Caffeine Intoxication
  • Caffeine-induced Sleep Disorder
  • Cancer
  • Cancer-Bladder
  • Cancer-Breast
  • Cancer-Cervical
  • Cancer-Colon
  • Cancer-Esophageal
  • Cancer-Gastrointestinal
  • Cancer-Kidney
  • Cancer-Leukemia
  • Cancer-Leukoplakia
  • Cancer-Lung
  • Cancer-Lymphoma
  • Cancer-Malignant Neoplasm: Mouth, Unspecified
  • Cancer-Medullary Thyroid Carcinoma
  • Cancer-Melanoma
  • Cancer-Mouth
  • Cancer-Multiple Myeloma
  • Cancer-Ovarian
  • Cancer-Pancreatic
  • Cancer-Pituitary
  • Cancer-Prostate
  • Cancer-Renal Cell Carcinoma
  • Cancer-Skin
  • Cancer-Stomach
  • Carbon Monoxide Poisoning
  • Carcinoid
  • Cataract
  • Cerebellar Disease
  • Cervical Spondylosis
  • Charcot-Marie-Tooth Disease
  • Charles Bonnet Syndrome
  • Chlamydia Infection
  • Choledocholithiasis
  • Cholesteatoma
  • Chorea Gravidarum
  • Chronic Daily Headache
  • Chronic Fatigue Syndrome
  • Chronic Kidney Failure (CKD)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Chronic Pain
  • Chronic Renal Failure
  • Circadian Rhythm Sleep Disorder
  • Cluster Headache
  • Cocaine Abuse
  • Cocaine Dependence
  • Cocaine Dependence In Remission
  • Coital Cephalgia
  • Coital Cephalgia-dull Type
  • Coital Cephalgia-explosive Type
  • Coital Cephalgia-postural Type
  • Collagen Vascular Disease
  • Conduct Disorder
  • Congestion-Drug-induced
  • Congestive Heart Failure
  • Congestive Heart Failure (CHF)
  • Constipation
  • Conversion Disorder
  • COPD
  • Costochondritis
  • Cranial Nerve Palsy
  • Creutzfeldt-Jakob
  • Creutzfeldt-Jakob Disease
  • Crohn's Disease Or Regional Enteritis
  • Cushing's Disease
  • Cystic Fibrosis
  • Cystitis
  • Cystitis, Unspecified
  • Deep Vein Thrombosis
  • Dehydration
  • Delirium
  • Delirium-Aneurysmal Subarachnoid Hemorrhage
  • Delirium-Lewy Body Dementia
  • Delirium-Postconcussion Syndrome
  • Delirium-Traumatic Brain Injury
  • Delusional Disorder
  • Delusional Disorder-erotomanic
  • Delusional Disorder-jealousy
  • Delusional Erotomania
  • Delusional Jealousy
  • Dementia
  • Dementia Amnestic Disorder
  • Dementia NOS
  • Dementia Vascular
  • Dementia-Alzheimers
  • Dental-Poor Fitting Dentures
  • Dental-Poor Hygiene
  • Dependent Personality
  • Depersonalization Disorder
  • Depression
  • Depression-Bereavement
  • Dermatopolymyositis
  • Diabetes Insipidus
  • Diabetes Mellitus
  • Diarrhea
  • Disease Of The Small Intestine, Unspecified
  • Disease Of Anus And Rectum, Unspecified
  • Disease Of Biliary Tract, Unspecified
  • Disease Of Intestine, Unspecified-Colon Proximal
  • Disease Of Intestine, Unspecified-Small Intestine
  • Disease Of Stomach And Duodenum, Unspecified
  • Disease Of The Proximal Colon, Unspecified
  • Disequilibrium-Benign Paroxysmal Positional Vertigo (BPPV)
  • Disequilibrium-Central Vertigo
  • Disequilibrium-Cerebellar Disease
  • Disequilibrium-Friedreich\'s Ataxia
  • Disequilibrium-Labyrinthitis Acute
  • Disequilibrium-Vertigo-Medication-induced
  • Disequilibrium-Vertigo-Peripheral
  • Disequilibrium-Vertigo-Toxin-induced
  • Disequilibrium-Vestibular Neuritis
  • Disorder Of Brain, Unspecified-Brainstem Or Pons
  • Disorder Of Brain, Unspecified-Hemisphere
  • Disorder Of The Brainstem Or Pons, Unspecified
  • Disorder Of The Cerebral Hemisphere, Unspecified
  • Disorder-Body Dysmorphic
  • Disorder-Impulse Control
  • Disorder-Intermittent Explosive
  • Disruptive Behavior Disorder
  • Disruptive-Conduct Disorder
  • Dissociative Disorder
  • Dissociative Identity Disorder
  • Dissociative-Depersonalization Disorder
  • Diuretic-induced Hypokalemia
  • Diverticulitis
  • Diverticulosis
  • Drug Induced Edema
  • Dry Mouth
  • Dyspareunia
  • Dysthymia
  • Early Morning Awakening
  • Eating Disorder
  • Eating Disorder, Medication-induced
  • Eating Disorder-Binge
  • Eating-Anorexia Nervosa
  • Eating-Bulimia
  • Eating-Laxative/Diuretic Abuse
  • Eating-Obesity
  • Eating-Reactive Hyperphagia
  • Eating-Weight Gain-Drug-induced
  • Edema
  • Edema-Drug Induced
  • Electrolytes-Magnesium-Hypomagnesemia
  • Electrolytes-Potassium Deficiency
  • Empty
  • Empty
  • Empty
  • Empty
  • Empty
  • Empty
  • Empty
  • Empty
  • Empty
  • Empty
  • Endocrine Disease-Adrenal
  • Endocrine-Adrenal Disease
  • Endocrine-Adrenal Insufficiency-Addison's Disease
  • Endocrine-Adrenal-Cushing's
  • Endocrine-Adrenal-Hyperaldosteronism
  • Endocrine-Carcinoid
  • Endocrine-Diabetes Mellitus
  • Endocrine-Diabetes Mellitus-Hypoglycemia
  • Endocrine-Gout
  • Endocrine-Hyperparathyroidism
  • Endocrine-Hyperparathyroidism - Primary Type
  • Endocrine-Hyperparathyroidism - Tertiary Type
  • Endocrine-Hypogonadism
  • Endocrine-Hypoparathyroidism-reversable
  • Endocrine-Hypopituitarism
  • Endocrine-Hypothyroidism
  • Endocrine-Metabolic Syndrome
  • Endocrine-Pancreatic Disease
  • Endocrine-Pancreatitis
  • Endocrine-Pheochromocytoma
  • Endocrine-Pituitary Adenoma
  • Endocrine-Porphyria Acute Intermittent
  • Endocrine-Thyroid-Hyper
  • Endocrine-Thyroid-Hypo
  • Enuresis
  • Enuresis/Bedwetting
  • Epilepsy-Seizure-Absence (petit Mal)
  • Epistaxis
  • Erectile Dysfunction
  • Erosive Esophagitis
  • Erythema-Drug Induced
  • Essential Palatal Tremor
  • Essential Tremor
  • Estrogen Related Hair Growth
  • Excessive Daytime Sleepiness
  • Exhibitionism
  • Eye-Cataract
  • Eye-Glaucoma
  • Factitious Disorder
  • Fainting
  • Fatigue
  • Fatigue-Chronic Fatigue Syndrome
  • Fatigue-Myasthenia Gravis
  • Female Orgasmic Disorder
  • Female Pattern Baldness
  • Female Sexual Arousal Disorder
  • Fetishism
  • Fibromyalgia
  • Fluid-Dehydration
  • Fluid-Polydipsia Psychogenic
  • Fluid-Polydipsia Secondary
  • Fluid-Weight Change
  • Flush-Aldehyde Dehydrogenase Deficiency
  • Flushing
  • Flushing Of Skin Due To A Spinal Cord Lesion Above T6
  • Flushing Of The Skin
  • Flushing-Drug Induced
  • Flushing-Gustatory Flushing Syndrome
  • Flushing-Harlequin Syndrome
  • Flushing-Mastocytosis
  • Flushing-VIPoma
  • Folic Acid Deficiency
  • Food Allergy
  • Friedreich\'s Ataxia
  • Frotteurism
  • Gallbladder Disease
  • Gallbladder Disease-choledocholithiasis
  • Gastric Or Peptic Ulcer
  • Gastritis
  • Gastroenteritis
  • Gastroesophageal Reflux Disease (GERD)
  • Gender Identity Disorder
  • Generalized Anxiety Disorder
  • Giant Cell Arteritis
  • Gingivitis
  • Glaucoma
  • Glomus Tumor (paraganglioma)
  • Glomus Tumors
  • Gluten-Celiac Disease
  • Gonorrhea
  • Gout
  • Guillain-Barre Syndrome
  • Gustatory Flushing Syndrome
  • Hair-Alopecia-Male Pattern Baldness
  • Hair-Balding-Alopecia Areata
  • Hair-Balding-Alopecia Medication-induced
  • Hair-Balding-Alopecia Secondary To Childbirth
  • Hair-Balding-Alopecia Universalis
  • Hair-Balding-Alopecia-Telogen Effluvim
  • Hair-Balding-Alopecia-Traction
  • Hair-Estrogen Related Hair Growth
  • Hair-Female Pattern Baldness
  • Hair-Tinea Capitis
  • Hair-Trichotillomania
  • Hallucination
  • Hallucination-Gustatory
  • Hallucinations
  • Harlequin Syndrome
  • Head Trauma
  • Head-Trauma To Scalp
  • Headache
  • Headache-Chronic Daily Headache
  • Headache-Cluster Headache
  • Headache-coital Cephalgia
  • Headache-Coital Cephalgia -dull Type
  • Headache-Coital Cephalgia -explosive Type
  • Headache-Coital Cephalgia -postural Type
  • Headache-Hemicrania Continua
  • Headache-Medication Overuse
  • Headache-Migraine
  • Headache-Migraine Probable
  • Headache-Migraine Status
  • Headache-Migraine With Aura
  • Headache-Migraine Without Aura
  • Headache-Migraine-Retinal
  • Headache-Psychogenic
  • Headache-sinus
  • Headache-Tension
  • Hearing
  • Hearing Problem
  • Hearing-Medication-induced Loss
  • Hearing-Meniere's Disease
  • Hearing-Tinnitus
  • Hearing-Traumatic Tinnitus
  • Heart Cardiac
  • Heart Disease
  • Heart-Angina
  • Heart-Angina - Emergency
  • Heart-Arrhythmia
  • Heart-Bacterial Endocarditis
  • Heart-CHF
  • Heart-Claudication-Intermittent
  • Heart-claudication-Neurogenic
  • Heart-HCM
  • Heart-MI
  • Heart-Mitral Stenosis
  • Heart-Pericarditis
  • Heavy Smoker
  • Heavy Tobacco Smoker
  • Hematemesis
  • Hematochezia
  • Hematuria
  • Hemicrania Continua
  • Hemochromatosis
  • Hemoptysis
  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Hepatitis E
  • Hepatitis G
  • Hepatolenticular Degeneration-Wilson's Disease
  • Heroin Abuse
  • Heroin Dependence
  • Heroin Dependence In Remission
  • Hiatal Hernia
  • Hip Pain
  • Histrionic Personality
  • HIV Infection
  • Homicide
  • Huntington's Disease
  • Hyperaldosteronism
  • Hypercalcemia
  • Hypercholesterolemia
  • Hyperhidrosis-Idiopathic
  • Hyperparathyroidism
  • Hyperparathyroidism - Primary Type
  • Hyperparathyroidism - Tertiary Type
  • Hyperprolactinemia
  • Hypersomnia
  • Hypertension
  • Hyperthyroidism
  • Hypertriglyceridemia
  • Hypertrophic Cardiomyopathy
  • Hypoactive Sexual Desire
  • Hypoactive Sexual Desire Disorder
  • Hypochondriasis
  • Hypoglycemia
  • Hypogonadism
  • Hypokalemia
  • Hypokalemia
  • Hypokalemia-Diuretic-induced
  • Hypomagnesemia
  • Hypoparathyroidism
  • Hypoparathyroidism-reversable
  • Hypopituitarism
  • Hypothyroidism
  • Hypothyroidism
  • Idiopathic Hyperhidrosis
  • Impulse Control Disorder
  • Incomplete Bladder Emptying
  • Incontinence-stress Type
  • Incontinence-unaware Type
  • Incontinence-Urge
  • Incontinence-urge Type
  • Increased Intracranial Pressure
  • Infection-AIDS
  • Infection-Creutzfeldt-Jakob
  • Infection-Gonorrhea
  • Infection-HIV
  • Infection-Lyme Disease
  • Infection-Malaria
  • Infection-Rheumatic Fever
  • Infection-Syphilis
  • Infection-Urinary Schistosomiasis
  • Infection-Viral Infection
  • Inferior Temporal Lobe Seizure
  • Inflammatory Disease Of Uterus, Unspecified
  • Inhalant Abuse
  • Inhalant Dependence In Remission
  • Initial Insomnia
  • Insomnia
  • Insomnial-Early Morning Awakening
  • Intermittent Claudication
  • Intermittent Explosive Disorder
  • Intracranial Pressure - Increased
  • Involuntary Emotional Expression Disorder (IEED)
  • Iron Deficiency
  • Irritable Bowel Syndrome (IBS)
  • Kidney Disease
  • Kidney Stone
  • Kidney-Alport Syndrome
  • Kidney-Chronic Renal Failure
  • Kidney-Diabetes Insipidus
  • Kidney-Pyelonephritis
  • Kidney-Renal Failure
  • Kidney-Renal-Failure-Acute
  • Kidney-Uremia
  • Kleine-Levin Syndrome
  • Kleptomania
  • Knee Pain
  • Labyrinthitis Acute
  • Lactase Deficiency
  • Lactose Intolerance
  • Laxative/Diuretic Abuse
  • Lead Toxicity
  • Learning Disorder
  • Leukoplakia
  • Lewy Body Dementia
  • Liver Cirrhosis
  • Liver Disease
  • Liver Disease - Cirrhosis
  • Liver Disease-autoimmune Hepatitis
  • Liver-Cirrhosis-billary
  • Liver-Common Bile Duct Obstruction
  • Liver-Hepatitis B
  • Liver-Hepatitis C
  • Liver-Hepatitis D
  • Liver-Hepatitis E
  • Liver-Hepatitis G
  • Liver-Hepatolenticular Degeneration-Wilson's Disease
  • Liver-Viral Hepatitis
  • LSD Abuse
  • LSD Dependence
  • LSD Dependence In Remission
  • Lung-Asthma
  • Lung-Bronchiectasis
  • Lung-Bronchitis
  • Lung-COPD
  • Lung-Pleurisy
  • Lung-Pneumonia
  • Lung-Pulmonary Embolism
  • Lung-TB
  • Lupus Erythematosus
  • Lupus Erythematosus-Drug Induced
  • Lyme Disease
  • Magnesium-Hypomagnesemia
  • Malabsorption
  • Malaria
  • Male Orgasmic Disorder
  • Malignant Neoplasm Of Mouth, Unspecified
  • Malnutrition
  • Malnutrition-Gluten-Celiac Disease
  • Manganese Toxicity
  • Marijuana Abuse
  • Marijuana Dependence
  • Marijuana Dependence In Remission
  • Mastocytosis
  • Medication Overuse Headache
  • Medication-induced Eating Disorder
  • Medication-induced Erythema
  • Medication-induced Flushing
  • Medication-induced Hearing Loss
  • Meiges Syndrome
  • Melena
  • Meniere's Disease
  • Menopause
  • Menopause-Drug Induced
  • Menopause-early
  • Menopause-Perimenopause
  • Menopause-Postmenstrual Duress
  • Menopause-surgical
  • Mental Retardation
  • Meprobamate Abuse
  • Meprobamate Dependence
  • Meprobamate Dependence In Remission
  • Meprobamate Use
  • Mercury Toxicity
  • Mescaline Abuse
  • Mescaline Dependence
  • Mescaline Dependence In Remission
  • Metabolic Syndrome
  • Metal Toxicity-Aluminum
  • Metal-Aluminum
  • Metal-Arsenic
  • Metal-Boron
  • Metal-Lead
  • Metal-Mercury
  • Metal-Selenium
  • Metal-Tellurium
  • Metal-Zinc
  • Middle Insomnia
  • Migraine Headache
  • Migraine Headache-probable
  • Migraine Headache-retinal
  • Migraine Headache-status
  • Migraine Headache-with Aura
  • Migraine Headache-without Aura
  • Mitral Valve Stenosis
  • Movement Disorder
  • Movement-Akathisia-Neuroleptic-induced
  • Movement-ALS
  • Movement-Chorea Gravidarum
  • Movement-CTD-Polymyalgia Rheumatica
  • Movement-Dermatopolymyositis
  • Movement-Essential Tremor
  • Movement-Guillain-Barre Syndrome
  • Movement-Huntington's
  • Movement-Myoclonus
  • Movement-Parkinson's
  • Movement-Parkinsonism
  • Movement-Tardive Dyskinesia
  • Movement-Tic Disorder
  • Movement-Tourette's Disorder
  • Movement-Transient Tic Disorder
  • Multiple Sclerosis
  • Myasthenia Gravis
  • Myocardial Infarction
  • Myoclonic Seizure
  • Myoclonus
  • Narcissistic Personality
  • Narcolepsy
  • Nasal Congestion-Rebound Congestion
  • Neurodermatitis
  • Neurofibromatosis
  • Neurofibromatosis-I
  • Neurofibromatosis-II
  • Neurogenic Claudication
  • Neuroleptic Malignant Syndrome
  • Neuropathies
  • Night Eating Syndrome
  • Night Sweats
  • Nightmare Disorder
  • Nocturia
  • Nonadherence
  • Nonne-Milroy's Disease
  • Nose Bleed
  • Nutrition-Iron Deficiency
  • Nutrition-Lactose Intolerance
  • Nutrition-Malabsorption
  • Nutrition-Malnutrition
  • Nutrition-Thiamine B1 Deficiency
  • Nutrition-Tropical Sprue
  • Nutrition-Vitamin-Avitaminosis
  • Nutrition-Vitamin-B12 Deficiency
  • Nutrition-Vitamin-B5-Pantothenic Acid Deficiency
  • Nutrition-Vitamin-B6-Pyridoxine Deficiency
  • Nutrition-Vitamin-B9-Folic Acid Deficiency
  • Nutrition-Vitamin-D Deficiency
  • Obesity
  • Obsessive-compulsive Disorder (OCD)
  • Obstruction Intestinal
  • Obstruction-Common Bile Duct
  • OCD
  • OCD Personality
  • OCD-medication Induced
  • Olfactory Hallucinations
  • Opioid Abuse
  • Opioid Dependence
  • Opioid Dependence In Remission
  • Optic Neuritis
  • Oral Cancer
  • Oral Facial Dystonia
  • Oral-Dry Mouth
  • Oral-Gingivitis
  • Orgasmic Disorder
  • Orgasmic Disorder-Female
  • Orgasmic Disorder-males
  • Orthostasis
  • Osteoporosis
  • Other And Unspecified Lesions Of Oral Mucosa
  • Overactive Bladder
  • Pain Abdominal Chronic
  • Pain Abdominal Infarction
  • Pain Disorder
  • Pain Disorder Due To Anatomical And Psychological Conditions
  • Pain Disorder-Psychiatric
  • Pain Disorder-Psychological & General
  • Pain-Abdomen-Acute
  • Pain-Abdominal
  • Pain-Abdominal-Localized To The Lower Abdomen
  • Pain-Abdominal-Localized To Upper Abdomen
  • Pain-Abdominal-Perforation Of Viscus
  • Pain-Abdominal-Visceral
  • Pain-Bowel-Obstruction
  • Pain-Branchial Neuralgia
  • Pain-Chronic Pain
  • Pain-Costochondritis
  • Pain-Erosive Esophagitis
  • Pain-Gastric Ulcer
  • Pain-Heartburn-Gastroesophageal Reflux Disease
  • Pain-Hip
  • Pain-Irritable Bowel Syndrome (IBS)
  • Pain-Peptic Ulcer Disease (PUD)
  • Pain-Peritonitis
  • Pain-Thalamic Central Pain Syndrome
  • Pain-Ulcer
  • Pain-Ulcer-Duodenal
  • Pain-Ulcer-Zollinger-Ellison Syndrome
  • Pancreatic Disease
  • Pancreatic Disease Unspecified
  • Pancreatitis
  • Panic Attacks
  • Panic Disorder
  • Pantothenic Acid Deficiency
  • Paranoid Personality
  • Paraphilia
  • Parkinson's Disease
  • Partial Seizure
  • Partial Seizures
  • Partialism
  • Pathological Gambling
  • Pathological Gambling-medication Induced
  • PCP Dependence
  • PCP Dependence In Remission
  • Pedophilia
  • Pedophilia Exclusive
  • Pedophilia Limited To Incest
  • Pelvic And Perineal Pain
  • Pelvic Inflammatory Disease
  • Pelvic Inflammatory Disease (PID)
  • Perforation Of Viscus
  • Pericarditis
  • Perimenopause
  • Periodic Limb Movement Disorder
  • Peripheral Neuropathy
  • Peripheral Vascular Disease
  • Peripheral Vascular Disease (PVD)
  • Peritonitis
  • Personality Avoidant
  • Personality Disorder
  • Personality-Antisocial
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  • Cushing's Disease and Cushing's Syndrome

    Cushing's disease and syndrome take there name from the physician Harvey Cushing who, in 1910, was one of the first to report the observation of the disease caused by excessive cortisol (a glucocorticoid). Prolonged exposure to elevated levels of either excessive amounts cortisol produced by the body (endogenous) glucocorticoids, or large doses of glucocorticoid medication from outside of the body (exogenous) over an extended period of time.

    Effects of Increased Cortisol or Long-Term Therapy with Glucocorticoid Medications

    System

    Effects

    Endocrine and metabolic

    Suppression of hypothalamic-pituitary-adrenal (HPA) axis (adrenal suppression)



    The face stays red and continues to get rounder

     

    Growth failure in children



    Hyperinsulinemia/insulin resistance



    Abnormal glucose tolerance test result/diabetes mellitus


    Gastrointestinal

    Gastric irritation, peptic ulcer


    Acute pancreatitis (rare, secondary to insulin resistance and hypertriglyceridemia)

    Cushing's DISEASE and Endogenous Cushing's SYNDROME are both due the overproduction of the adrenal hormone cortisol. If caused by medication, then it is called Exogenous Cushing's SYNDROME, and high-doses of cortisol-like glucocorticoids taken over relatively long periods are required to produce the condition.

    Normally, the pituitary produces the hormone ACTH that travels in the blood from the brain to the adrenal glands on the kidneys. The ACTH causes the adrenal glands to produce cortisol. The cortisol produced feeds-back on the hypothalamus turning off the stimulation of CRH release and thus the production of more cortisol. However, if this system is disturbed at any point in the pathway, then an abnormal amount of cortisol is produced.

    Cushing's DISEASE

    Cushing's DISEASE is the overproduction of cortisol by the adrenal glands that is caused by the pituitary gland producing too much adrenocorticotropic hormone (ACTH).

     

    This overproduction of ACTH is caused by pituitary adenomas (tumors of the pituitary gland) that secrete ACTH, and with time they produce Cushing's disease symptoms.

     

     

    Cushing’s disease (pituitary tumors) can also cause compression of nearby structures producing chronic headache, visual dysfunction, polyuria, nocturia, or galactorrhea. The compression of the pituitary gland itself can interfere with the production of other pituitary hormones causing hypopituitarism and specifically hyposomatotropism, hypothyroidism, hyperprolactinemia or hypoprolactinemia, and hypogonadism.

    Cushing's Disease Symptoms

    The unregulated secretion of ACTH by a pituitary tumor causes abnormally high levels of cortisol. Cortisol is a very potent hormone and even slight increases in cortisol over time can result in significant symptoms. Too much cortisol in the blood -- a condition called hypercortisolemia -- affects almost every organ in the body, and can cause hypertension, diabetes mellitus, osteoporosis, rounding of the face, truncal weight gain, stretch marks from thinning of the skin (abdominal striae), and development of an upper back fat pad ("buffalo hump").

     

    When the cause of Cushing disease -- a pituitary tumor – is left untreated, it can sometimes grow and lead to other problems, such as interfering with the production of other hormones controlled by the pituitary.

    Cushing's SYNDROME

    Cushing's SYNDROME is the overproduction of the hormone cortisol by the adrenal glands that is NOT due to the pituitary gland overproducing ACTH. 

    Greater than 99% of cases of Cushing's SYNDROME are due to taking large amounts of exogenous glucocorticoid medication for a prolonged period of time. These medications have the same effects as does the cortisol produced produced by the body, and because the doses required are often higher than the amount of cortisol your body normally needs each day, the effects of excess cortisol can occur.

    This type of medication-induced Cushing's SYNDROME is sometimes seen when people take high-doses for long periods of cortisol-like medications such as glucocorticoid drug hormones (e.g., hydrocortisone, prednisone, methylprednisolone, or dexamethasone). Glucocorticoids can be categorized as short, intermediate, or long acting, based on their biologic effective half-life.

    Glucocorticoid Equivalencies

    Type

    Drug

    Dose

    Relative Glucocorticoid Potency

    Relative Mineralocorticoid Potency

    Plasma Half-Life



    (mg)


    Biologic Half-Life



    (h)


    Short-acting

    Cortisol

    20

    1.0

    2

    90

    8-12

    Hydrocortisone

    25

    0.8

    2

    80-118

    8-12

    Intermediate-acting

    Prednisone

    5

    4

    1

    60

    18-36

    Prednisolone

    5

    4

    1

    115-200

    18-36

    Triamcinolone

    4

    5

    0

    30

    18-36

    Methylprednisolone

    4

    5

    0

    180

    18-36

    Long-acting

    Dexamethasone

    0.5

    25-50

    0

    200

    36-54

    Betamethasone

    0.6

    25-50

    0

    300

    36-54

    Mineralocorticoid

    Aldosterone

    0.3

    0

    300

    15-20

    8-12

    Fludrocortisone

    2

    15

    150

    200

    18-36

    Desoxycorticosterone acetate

    0

    0

    20

    70

     

    In addition, Cushing's syndrome can be caused by the adrenal glands themselves producing an excessive amount of cortisol, such as a tumor within the adrenal gland overproducing cortisol or by some source other than the pituitary gland producing excess ACTH.

     

    Cushing’s Syndrome Genetics

    Most cases of Cushing’s syndrome are not genetic. However, it appears that the cells of Cushing's patients struggle to maintain their DNA stability in general, but some individuals develop Cushing’s syndrome due to an inherited tendency to develop tumors of one or more endocrine glands. The various syndromes that have Cushing disease as a feature can have different inheritance patterns. Most of these disorders are inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder.

    Researchers at cortisol LMU Medical Center in Munich, Germany identified genetic mutations that caused the uncontrolled synthesis and secretion of the stress hormone cortisol, resulting in ACTH-independent Cushing's disease. In the study, one-third of a patient population with adrenal tumors were found to have a mutation in the gene for the enzyme phosphokinase A. This gene mutation was specifically associated with the continuous production of cortisol, and it appears that the mutation causes it to become irreversibly activated, which results in the unrestrained production of cortisol.

     In Multiple Endocrine Neoplasia Type I (MEN I), hormone secreting tumors of the parathyroid glands, pancreas and pituitary occur. Cushing’s syndrome in MEN I may be due to pituitary, ectopic or adrenal tumors.

    Familial isolated pituitary adenoma (FIPA) is an inherited condition characterized by development of a nonmalignant tumor in the pituitary gland (called a pituitary adenoma). FIPA can be caused by mutations in the AIP gene, and is inherited in an autosomal dominant pattern, which means one copy of the altered gene in each cell is sufficient to cause the disorder. The AIP gene produces a protein that it is thought to act as a tumor suppressor, which means it helps prevent cells from growing and dividing in an uncontrolled way. Mutations in the AIP gene alter the AIP protein or reduce the production of it. These changes impair the ability of the AIP protein to control the growth and division of cells, allowing pituitary cells to grow and divide unchecked and form a tumor. However, only 20 to 30 percent of individuals with an AIP gene mutation develop a pituitary adenoma.

     

    In Primary Pigmented Micronodular Adrenal Disease is a rare cause of ACTH-independent Cushing's syndrome, and children or young adults develop small cortisol-producing tumors of both adrenal glands. Bilateral adrenalectomy is the treatment of choice. (see Carney complex in the table below).

     

     

    Cushing Syndrome Genetic Causes

    Cause

    Features

    Genetics

    Multiple endocrine neoplasia type 1 (MEN1)

    Associated with pancreatic tumors producing gastrin, insulin, and/or ACTH that may metastasize to the liver;



    multigland hyperparathyroidism, pituitary tumors, lipomas, and angiofibromas


    11p13



    (MIM 131100)


    McCune-Albright syndrome

    Mosaic constitutively activating postzygotic GS alpha mutation that can lead to polyostotic fibrous dysplasia, pigmented skin lesions, gonadotropin-releasing hormone–independent precocious puberty, hyperthyroidism, renal phosphate wasting, and other endocrine and nonendocrine manifestations

    20q13.2



    (MIM 174800)


    Beckwith-Wiedemann syndrome (Risk of adrenal malignancy)

    Macroglossia; visceromegaly; hyperinsulinemia; omphalocele; and risk of adrenal carcinoma, nephroblastoma, hepatoblastoma, rhabdomyosarcoma, and thoracic neuroblastoma requiring biannual sonograms

    11p13



    (MIM 130650)


    Hemihypertrophy (Risk of adrenal malignancy)

    Adrenal tumors in association unilateral tissue overgrowth on ipsilateral or contralateral side



    Compare upper and lower limbs and look for facial asymmetry


    (MIM 235000)[6]

    Li-Fraumeni syndrome(Risk of adrenal malignancy)

    Adrenal neoplasm



    Personal or family history of multiple tumors (eg, lung, breast, nasopharynx, CNS, melanoma, pancreas, gonads, prostate)


    17p13.1 -TP53gene



    22q12.1



    (MIM 191170; 151623)


    Carney complex

    Primary pigmented nodular adrenal disease (PPNAD); lentigines; myxomas of the heart, skin, and breast; melanotic schwannoma; growth hormone– and prolactin-secreting pituitary adenomas; Sertoli cell tumors of the testis; multiple small hypoechoic thyroid lesions; thyroid carcinoma

    2p16 and 17q22-24



    (MIM 605244; 160980)


     

     

     

    No matter the cause of increased cortisol or the presence of large doses of cortisol-like medication, over time the results cause a series of morphological changes as depicted in the drawing below.

    Photograph of the reddish-purple stria seen in people with Cushing's.

     

    Cushing’s disease and syndrome are rare disorders and cause symptoms that can be mistaken for a different, more common condition. These conditions include pregnancy, depression or other psychiatric disorders, alcoholism, weight problems (obesity) caused by improper diet and/or exercise, poorly controlled diabetes mellitus, and polycystic ovarian syndrome (PCOS).

    If you believe you have Cushing's disease or syndrome, then you should see then see your healthcare provider or a Family Practice, Internal Medicine, or Endocrinology specialist.

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