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Dare u with this tricky endo case ,"snickers" inside :)


Dare u with this tricky endo case ,"snickers" inside :)


حالة سريرية

كتابة حرة وطرح موضوع النقاش!
You are asked to see a 48 y/o Caucasian man who was admitted to ICU for hypotension.He is not able to give a Hx and no acquaintances have been located .He was involved in a car accident after a late-season snowstorm and suffered a broken thumb.A witness said he appeared ok after the accident except for some pain in his hand ,but he passed out a few mins later.The orthopedic surgeon repoerted a simple fracture and placed a cast on his hand .The ER physician was unable to explain the BP of 75 .
U note that he is thin,tanned ,and has a sparse axillary hair.His skin is moist and warm.He denies fatigue or cold intolerance,BP is 100/64 while on IV saline.HR was 130 in ER but now is 80.Temp is 37.2 C.
Labs shows:
Prerenal azotemia
hyperkalemic metabolic acidosis
and Glucose 61
Head CT is unremarkable.
Which of the following should u do now>???
1-Begin hydrocortisone every 8 hrs.
2-Begin hydrocortisone every 8 hrs and order ACTH stimulation test.
3--Begin Dexamethasone every 8 hrs and order ACTH stimulation test.
4-Begin Thyroxin everyday.
5-Begin hydrocortisone every 8 hrs and thyroxin everyday.and order ACTH stimulation test and TSH
المرجع

later

mbs2380's picture
by
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a piece of snicker for the one who comes with an explicit answer Eye-wink

mbs2380's picture
mbs2380
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I love snicker, it is actually my favorite snack but I will leave the chance to our juniors.
Cool

Al Durra's picture
Al Durra
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well, i will go with C Eye-wink Eye-wink
Fouad's picture
Fouad
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الأعراض توحي بـ primary adrenal insufficincy
خاصة الـ hyperkalemic metabolic acidosis و أيضا hypotension
لذلك بعتقد -ماني متأكدة- أنو مو ضروري أجراء ACTH stimulation test
Rolling Eyes
I'll choose A

lonely
طبيب مقيم


The concept behind endocrinology is rather simple:
If you suspect hypo >>>> stimulate and see the response
If you suspect Hyper >>> supress and evaulte the reaction.

It is clear that we have features of adernal insufficiency (hypotension, hyperkalemic metabolic acidosis) and it is primary (since there is pigmentation: a sign of ACTH increase). and the history support the flare of symptoms after a stress ( car accident) . The next question is how to confirm diagnosis and treat at the same time realizing that patient has hypotension (serious condition ) and we can't delay treatment. So how do we treat and diagnose (and not let the treatment given interefer with the accuracy of the test) . Treatment is simle in principle : you lack steroid : give steroids, but which one to give becomes an issue dictated by your needs to achive the other goal : confirm diagnosis. Add snickers bar to the equation ( with all the stamina and euphoria) and you come to the conclusion ....

Giving the snickers to the patient is a reasonable option to consider

ABIM's picture
ABIM

Quote:
I love snicker, it is actually my favorite snack but I will leave the chance to our juniors.

Who doesn't Cool Cool

actually Fouad got it right ,but I think he's not yearning for any snickers as he gave it w/o explanation Eye-wink

Dr.Omar make it a "piece of cake" for u(oh,a lot of sugar there ) .
So the thing missing there is :
Why Dexa and not hydrocortisone???
-it's all there in dr.Omar's post-

Quote:
Add snickers bar to the equation ( with all the stamina and euphoria) and you come to the conclusion

Laughing out loud Laughing out loud

mbs2380's picture
mbs2380
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Quote:

actually Fouad got it right ,but I think he's not yearning for any snickers as he gave it w/o explanation

And don't forget that he owes for the three of us a family-size coke which is still pending....Cool
Al Durra's picture
Al Durra
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Quote:
And don't forget that he owes for the three of us a family-size coke which is still pending....Cool

Cool Cool

ٍSorry for being late,
We highly suspect here that the pt is having primary adrenal defficiency and remember that the pt is well tanned in a late-season snow storm !!!!! Yup,it's the high ACTH
the idea here is with the fact that we wanna manage the pt but at the same time we don't wanna screw up the test used in confirming the diagnosis (the consytropin test)
The TX is with steroids .
All kinds of steroids interfere with the cortisol assay except Dexamethasone ,so if we have any suspicion that the pt has adrenal insuf,we should start him on Dexa not any other steroids.

And if the pt has hypothyroidsism along with adrenal insuf ;akaL Schmidt syndrome (and that';s not our pt ) ,NEVER EVER START HIM ON THYROID HORMONE BEFORE GIVING THE CORTONE,other wise u will end up dealing with a cadaver !!!

I hope u find it interesting cuz I really did.
The take-home message is :
All kinds of steroids interfere with the cortisol assay except Dexamethasone ,so if we have any suspicion that the pt has adrenal insuf,we should start him on Dexa not any other steroids.

-----------
By the way the guy on Medstudy Videos is AWESOME .

mbs2380's picture
mbs2380
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Quote:
,other wise

otherwise.

--------

Quote:
All kinds of steroids interfere with the cortisol assay except Dexamethasone ,so if we have any suspicion that the pt has adrenal insuf,we should start him on Dexa not any other steroids

When we suspect adrenal insufficiencty we give the pt consytropin (which blocks 11bhydroxylase ) the last step in cortisol synthesis) so ,low cortisol in a normal person will urge the piuitary to secretes ACTH ,but here in pt with primary adrenal insuff,where the problem is in the adrenal gland, ,the ACTH is secreted and adrenals are not responding and that we can measure (the response) by measuring cortisol.
Now the big point in this case,measurement of most of hormones depends on antibodies to that hormone.So if we treat hour pt in this case with hydrocortisone and then we did the conytropin test ,we would have a false insensitive results as a result of interference iof hydrocortisone with the cortison assay .Dexamethasone does not interfere and that's the rationale of using it here.

Note: Hydrocortisone may not that problem cuz it has a short half-life.Yanee we can do the test after getting rid of it.Prenisone on the other hand is a problem
Sorry for the typos
Salam

mbs2380's picture
mbs2380
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BTW,consytropin test was on my step1 exam

mbs2380's picture
mbs2380
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