!!!!Adrenal insufficiency !!!!! Flashcards
A 32 year old man presents to A+E with {{{vomiting, }}}
{{{abdominal pain}}}
and {{{{{confusion}}}}}. You have been asked to see him on the medical take. The nurse calls you as she is concerned about his observations.
She tells you that the patient’s girlfriend has indicated he has been {{{{{{{{feeling increasingly weak and lethargic over the last week}}}}}}}}}}}
He started {{{{{{{vomiting }}}}}}}}today so she called the doctor who sent them to A+E.
She is concerned, as the patient has been {{{{{{{losing weight over the last 4 months}}}}}}}} without any known cause. He has also been having {{{{{{{dizzy spells and fainted two weeks ago}}}}}}}
His observations are as follows:
{{{{{{{Blood Pressure: 87/54}}}}}
Heart Rate: 120. Regular
{{{{{{{Respiratory rate: 24}}}}}
Saturations: 100% room air
{{{{{{{Temperature 37.8 degrees}}}}}
On arrival the nurse shows you his VBG:
{{{{{{{pH 7.49}}}}}
pCO2 4.7
HCO3- 28
{{{{{{{Na+ 115}}}}}
{{{{{{{K+ 5.3}}}}}
{{{{{{{Glu 3.9}}}}}
{{{{{{{Lac 3.7}}}}}
investigations would you do?
At the bedside I would take some routine blood tests including FBC, U+Es, CRP, LFTs (Abdominal pain), Thyroid function!!!!!!, Calcium, Magnesium and Amylase.
I would also send a random cortisol on this patient.
I would also send Blood cultures as the patient has signs of sepsis.
An ECG will be important, as the patient is tachycardic.
A chest XR and urine dip will be important to complete
There is no history of head trauma, however, the patient is increasingly confused and vomiting so I would perform a CT Head.!!!!!!!
!!!!!!!!!A CT abdomen may be warranted in this patient given the history of abdominal pain and raised lactate. I would discuss this with my senior first given the presentation.
I would discuss both of these scans with my registrar.
What is your differential diagnosis?
septic shock
could include Acute Pancreatitis or Liver Failure. In a patient with abdominal pain and hypovolameic shock I would want to make sure there is no history of abdominal pathology or trauma.
However, given the initial investigations – hyponatraemia, hypoglycaemia and history of weight loss and lethargy, I would be concerned about adrenal crisis causing this presentation.
My differential diagnosis would also include Hypothyroidism (myxoedema can present with similar symptoms to above although you would expect to see an altered conscious level).
acute pancreatitis
What do you understand by Adrenal Crisis?
Insufficient levels of the hormone cortisol and the inability of the body to produce more cortisol in response to stressors result in Adrenal Crisis. Patient’s present with a constellation of symptoms including dizziness, vomiting and in life threatening cases, altered consciousness. Severe hypotension and signs of shock are seen when these patients present.
What may precipitate Adrenal Crisis?
Common stressors include infection (this is the most common precipitating factor),
surgery,
anaesthesia,
trauma,
exogenous steroid withdrawal (for example in a patient who has been treated for an exacerbation of asthma).
How would you treat this patient if the diagnosis were Adrenal Crisis?
Treatment may be required before the diagnosis is confirmed.
General measures such as giving oxygen, broad spectrum antibiotics for infection and fluid balance monitoring should be started. The patient may require a catheter.
Shock should be treated with IV fluids such as normal saline 0.9%. 1L should be given stat and then subsequent bags titrated to response.
{{{{I would make sure that the patient’s sodium is repeated at 4 hours to make sure it’s correction is not too rapid.}}}}
Finally, the most important treatment for this patient is administration of glucocorticoids. Hydrocortisone should be given intravenously. (It is worth noting that commencing hydrocortisone can do little harm and may be life saving!). Continue with IV hydrocortisone before switching to oral steroids at 72 hours!!!!
Mineralocorticoid replacement once the patient is stable is achieved with fludrocortisone.
Monitor BM - dextrogel
The presentation is consistent with Adrenal crisis. What symptoms and signs would support an underlying diagnosis of Addison’s disease?
affects glucocorticoid and mineralocorticoid function.
most common physical sign is hyperpigmentation of the skin and mucous membranes.
Patients will typically be hypotensive with significant orthostatic hypotension.
The patient is also likely to have a low body mass index.
weakness, fatigue, nausea, vomiting and weight loss.
Addison’s disease typically associated with?
autoimmune thyroid disease,
premature ovarian failure, type 1 diabetes mellitus, vitiligo,
alopecia
and coeliac disease.
What information would you give to someone with Addison’s disease?
During times of stress (e.g. minor surgery, infections) patients should be instructed to double or triple their usual maintenance dose of steroid.
Patients should know to contact their GP or seek medical help in times of severe stress when oral uptake of steroid may be compromised – for example in severe vomiting or diarrhoea.
Patients should also be given instruction on how to administer IM injections in these scenarios
How would you investigate someone for primary adrenal insufficiency?
short synacthen test
a blood sample for a random cortisol should be taken prior to starting hydrocortisone. A random plasma cortisol of greater than 680nmol/L effectively excludes adrenal insufficiency.
What complications are you aware of with rapid correction of hyponatraemia?
correction in sodium concentration must not exceed 10 mmol/L in the first 24 hours and 18 mmol/L in the first 48 hours
result in osmotic demyelination known as cerebral pontine myelinolysis.
