A 20-year-old woman is brought to the emergency department due to intractable vomiting and abdominal pain. She has a several-week history of anorexia and weight loss. The patient has well-controlled primary hypothyroidism treated with levothyroxine but has not taken her medication for 2 days because of vomiting. Temperature is 37.6 C (99.7 F), blood pressure is 80/40 mm Hg, pulse is 120/min, and respirations are 18/min. On physical examination, she is mildly lethargic but oriented. Generalized hyperpigmentation is present and is most conspicuous over the face, neck, and dorsal surface of the hands. Urinalysis and chest x-ray are within normal limits. Finger-stick blood glucose is 60 mg/dL. A 1-L bolus of normal saline is rapidly infused, and high-flow intravenous fluids are continued. This patient also requires immediate treatment with which of the following medications?

Question

A 20-year-old woman is brought to the emergency department due to intractable vomiting and abdominal pain.  She has a several-week history of anorexia and weight loss.  The patient has well-controlled primary hypothyroidism treated with levothyroxine but has not taken her medication for 2 days because of vomiting.  Temperature is 37.6 C (99.7 F), blood pressure is 80/40 mm Hg, pulse is 120/min, and respirations are 18/min.  On physical examination, she is mildly lethargic but oriented.  Generalized hyperpigmentation is present and is most conspicuous over the face, neck, and dorsal surface of the hands.  Urinalysis and chest x-ray are within normal limits.  Finger-stick blood glucose is 60 mg/dL.  A 1-L bolus of normal saline is rapidly infused, and high-flow intravenous fluids are continued.  This patient also requires immediate treatment with which of the following medications?

Quizplus · Accepted Answer

11ec160b_3aaf_2266_9249_0db0564c221e_MD0001_00 This patient most likely has acute adrenal crisis. Her history of hypothyroidism puts her at increased risk for other autoimmune endocrinopathies (eg, autoimmune adrenalitis), and her weight loss and hyperpigmentation are suggestive of chronic primary adrenal insufficiency (Addison disease). In normal individuals, the adrenal glands respond to acute stress (eg, illness, surgery) with a compensatory increase in glucocorticoid production, but patients with adrenal insufficiency cannot mount such a response. Adrenal crisis is characterized by severe hypotension and refractory shock. Associated symptoms include abdominal pain, vomiting, weakness, and fever. In addition to aggressive fluid resuscitation, treatment of adrenal crisis requires immediate glucocorticoid supplementation with hydrocortisone or dexamethasone. Treatment should begin immediately without waiting for results of diagnostic studies, and the response is usually rapid. (Choice A) Antibiotics may be necessary if evidence of infection is found. However, treatment with glucocorticoids is warranted immediately, whereas the decision to start an antibiotic may be made when the presence of infection is more clearly established. (Choices C and D) Dopamine is used in the treatment of shock and refractory cardiac failure. Epinephrine is used in the treatment of anaphylaxis, severe asthma, and cardiac arrest. However, hypotension in adrenal crisis is often refractory to vasopressors because glucocorticoids have a permissive effect on vasoconstriction. (Choice E) Clinical features of hypothyroid crisis may include hypoglycemia and hypotension, as seen in this patient, but would usually also include altered sensorium, hypothermia, bradycardia, and hypoventilation. In addition, due to the long plasma half life of levothyroxine, missing 2 days of therapy would be unlikely to cause a symptomatic drop in thyroid hormone levels. Educational objective: Patients with adrenal insufficiency are not able to increase glucocorticoid production in response to acute stress (eg, illness, surgery). Adrenal crisis is characterized by severe hypotension, abdominal pain, vomiting, weakness, and fever. In addition to aggressive fluid resuscitation, treatment requires immediate glucocorticoid supplementation. __________ References: Extensive expertise in endocrinology. adrenal crisis. (http://www.ncbi.nlm.nih.gov/pubmed/25288693)

A 20-Year-Old Woman Is Brought to the Emergency Department Due