very ill - sith

[ArchivalUser]

A 51-year-old man is admitted to the hospital with the acute onset of hypotension, generalized weakness, and confusion. He has experienced progressive shortness of breath over the past two years, which occurs now even on minimal exertion. He has a history of multiple transient ischemic attacks (TIAs), a pulmonary embolus last year, and a chronic deep venous thrombosis (DVT). Evaluation for a hypercoagulable state was unrevealing. He has been on coumadin over the last year. His temperature is 100.2 F, blood pressure is 80/20 mm Hg, and pulse is 104/min. His skin is hyperpigmented. There is jugular venous distention and small testicles. He has a systolic murmur heard over the third to fourth intercostal space, along the left sternal border. On lung auscultation, there are crackles bilaterally, and the liver edge is palpable 3 cm below the right costal margin. There is bilateral leg edema, and the stool is guaiac-positive. His white cell count is 16,800/mm3. Other laboratory tests show: sodium 122 mEq/L, potassium 5.5 mEq/L, glucose 48 mg/dL, calcium 11.3 mg/dL, BUN 88 mg/dL, and creatinine 2.2 mg/dL. His prothrombin time is 34 seconds, INR is 4.5, and partial thromboplastin time is 64 seconds. The albumin level is 1.2 g/dL, and hematocrit is 28%. What would be most important initial step in the management of this patient?

(A) Order blood transfusion and start normal saline
(B) The cosyntropin stimulation test
© Send blood for cortisol and treat with hydrocortisone and normal saline
(D) Send blood and sputum cultures and start broad-spectrum antibiotics
(E) Vitamin K and fresh frozen plasma

[ArchivalUser]

vit-K and FFP
already overloaded, avoid fluids, low sodium is dilutional i guess
immediate concern maybe bleeding

[ArchivalUser]

C.is the answer

[ArchivalUser]

any exp sith

[ArchivalUser]

Acute adrenal insufficiency must be distinguished from other causes of shock, such as sepsis, the heart, or hemorrhage. Patients with acute adrenal insufficiency may present with headache, nausea, vomiting, mental status changes, hypoglycemia, hyperkalemia, hyponatremia, and hypercalcemia. The blood pressure is usually low. Fever may be as high as 40 C (104 F) or higher. Body fluid cultures may be positive if a bacterial infection is the precipitating cause. Adrenal crisis may occur following stress, trauma, infection, fasting, bilateral adrenalectomy, injury to adrenal glands by trauma, hemorrhage, thrombosis, anticoagulant therapy, or metastatic carcinoma. The diagnosis is made by a simplified cosyntropin-stimulation test. But if the diagnosis is suspected on a clinical basis, you should immediately draw a sample of blood for a cortisol level and start hydrocortisone and saline intravenously without waiting for results. Thereafter, continue hydrocortisone for at least several days. Rapid treatment is lifesaving.

[ArchivalUser]

what about bleeding in a patient on anticoagulants????

[ArchivalUser]

Adrenal insuficiency is an emergency, his sodium level is 122 this is a critical value, he is going to collapse, he is in shock and he will have a seizure because low sodium, besides hydrocortisone, normal saline I will givea mineralocorticoide, in the real scenario we have to.

[ArchivalUser]

he is edematous: dilutional hyponatremia
he has renal dysfunction: hyperkalemia
he has neck vein distenstion: CCF(that explains the low blood pressure)
he has hypercalcemia in presence of renal failure which makes it likely due to malignancy, also he may have chronic DIC causing recurrent thrombosis, and with malignancy u would more likely see cushing's rather than addison's.
he is already bleeding significantly in the GI tract and might bleed into the CNS or lungs anytime, also the bleeding has compromised cardiac function(distended neck veins), so maybe vit.k or blood, i wont give more fluids.