Free adrenal disorders board review questions sample from Med-Challenger.
Med-Challenger offers adrenal disorder review and other endocrinology, diabetes, and metabolism review questions along with everything else for diagnosing and treating a variety of endocrinology disorders and conditions. More free adrenal disorders review questions can be accessed via this week’s Quick Quiz, and via free trial of the following specialty courses:
This week’s case-based question:
A 32-year-old woman with a history of severe asthma presents to you with swelling, redness, fever, and heat in her left leg. You make a diagnosis of cellulitis and admit the patient for antibiotic therapy. She was recently treated for a severe exacerbation of asthma and continues on a tapering steroid regimen. However, she is unable to remember her current dose.
After being in the hospital for 12 hours, the patient’s fever worsens and she starts vomiting after complaining of nausea. In addition, she complains of fatigue and generally feeling weak. When the medical intern is asked to see the patient, she reports severe generalized abdominal pain.
On examination, her abdomen is rigid but it is difficult to elicit pain on any particular quadrant of the abdomen. Blood pressure is 110/74. Respiratory rate is 16 breaths per minute.
Labs drawn a few hours before reveal a potassium of 4.5 mEq/l, a sodium of 131 mEq/l, and a glucose of 50.5 mg/d L. Her white cell count is 8,300 cells/ml and her platelet count is 250,000.
Which of the following is the most important next step in the treatment of this patient?
Administer STAT morphine for the pain and consult surgery for acute abdomen.
Increase the rate of the fluids the patient is receiving to 150 cc/hour.
Administer STAT intravenous hydrocortisone 100 mg followed by 50 mg every 8 hour.
Order STAT chemistries, arterial blood gas values, and Synacthen test.
And the answer is …
Correct Answer:Administer STAT intravenous hydrocortisone 100 mg followed by 50 mg every 8 hour.
This 32-year-old woman has a history of asthma and presents with cellulitis. Because steroids are commonly used with patients with asthma, these patients are at a higher risk of having iatrogenic adrenal suppression and they are at higher risk for adrenal crisis when acutely ill. In this scenario, the patient’s overall condition is worsening and she presents with findings that suggest adrenal crisis (worsening fever, nausea, vomiting, and abdominal pain mimicking acute abdomen). Under these circumstances, immediate treatment with STAT intravenous hydrocortisone 100 mg followed by 50 mg every 8 hours is warranted. Fluid resuscitation therapy with 0.9 percent saline solution should also be commenced.
Chemistries, arterial blood gas levels, and an increase in intravenous fluids are also appropriate, but treatment should not be delayed when the diagnosis of adrenal crisis is suspected. If confirmation of adrenal insufficiency is being considered, then dexamethasone can be administered instead of hydrocortisone to prevent altering results for cortisol levels. Dexamethasone can be administered immediately and blood drawn once therapy is initiated.
Typically, patients with adrenal crisis due to secondary causes present with normal potassium, low sodium, and low glucose but with less severe dehydration and hypotension than those with primary disease.
Charmandari E, Nicolaides NC, Chrousos GP. Adrenal insufficiency. Lancet. 2014;383(9935):2152-2167.
Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
Nelson BK. Adrenal Crisis. Book Chapter in Emergency Medicine, 168, 1424-1428.e1.
Michels A, Michels N. Addison disease: early detection and treatment principles. Am Fam Physician. 2014;89(7):563-568.
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