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A 52-year-old man is evaluated in the hospital for persistent hypotension 24 hours after minor ankle surgery to repair a fracture. Before the fracture, the patient's only symptoms were chronic headache, general malaise, and fatigue over the past few months, and he adds on more detailed questioning that he has had occasional dizziness with standing and a 3-year history of erectile dysfunction. He had not been taking any prescription medications before his hospitalization and is currently taking only acetaminophen with codeine for postoperative pain control. Postoperative laboratory evaluation revealed a serum sodium of 132 meq/L (132 mmol/L), potassium of 4.8 meq/L (4.8 mmol/L), hematocrit of 35%, leukocyte count of 15,000/µL (15 × 109/L), and normal liver function tests. Chest radiograph and electrocardiography are also normal. Blood cultures drawn 24 hours ago are negative.
On physical examination, he is in mild pain and has a healing ankle incision. He is afebrile; the blood pressure is 88/56 mm Hg and pulse rate 110/min. He does not have hyperpigmentation, but there is decreased body hair. Cosyntropin (ACTH) stimulation test reveals a baseline cortisol of 1 µg/dL (27.59 nmol/L) that increased to 10 µg/dL (275.9 nmol/L) 30 minutes after 250 µg of ACTH.

In addition to measuring ACTH and starting corticosteroid replacement, which of the following is the most appropriate next step in the management of this patient?

A Measurement of serum follicle-stimulating hormone and luteinizing hormone
B MRI of the brain
C CT scan of the abdomen
D Empiric intravenous antibiotic therapy

C..

cc

dd

i know u want do ct/mri to look for cause of addisons
but ha has leucocytosis , so why not antibiotic

and if not antibiotic than MRI would be nest choice as he ha history of chronic headache

b.

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This patient most likely has central adrenal insufficiency. The ACTH level will indicate whether the patient has primary (ACTH will be elevated) or central (normal or low ACTH) adrenal insufficiency. Clinical features that suggest central adrenal insufficiency are the history of chronic headache consistent with possible mass effect from a pituitary adenoma and erectile dysfunction consistent with hypogonadism; therefore, MRI of the head would be indicated. The scant body hair also suggests hypogonadism. Hyperpigmentation is generally seen in patients with Addison's disease or primary adrenal insufficiency due to the high levels of ACTH and other propiomelanocortin cleavage products (such as alpha melanocyte stimulating hormone). The fact that this was not observed in this patient also suggests central adrenal insufficiency. Finally, the serum sodium and potassium levels were only minimally altered, supporting the diagnosis of central adrenal insufficiency. Electrolyte abnormalities are generally not observed in patients with central adrenal insufficiency due to the fact that the aldosterone system is still functional. Abdominal imaging would not be the first choice given the clinical features of this case. The patient was afebrile with no evidence of sepsis as a cause of his hypotension so empiric IV antibiotics is not the best answer.

good Q
thanks

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