A 68-year-old woman comes to the emergency department due to severe generalized weakness and dizziness. She has not fallen or lost consciousness. The patient reports no chest pain, dyspnea, cough, or diarrhea; however, she has had worsening fatigue, nausea, and anorexia for the past 3 weeks. The patient has a history of breast cancer treated with surgery and chemotherapy 5 years ago but was found to have a vertebral metastatic lesion during evaluation of back pain a month ago. Radiation therapy and systemic chemotherapy are planned, but she has not received treatment yet. The patient has no other medical conditions, and the only prescribed medication is opioid analgesic as needed. Temperature is 37.5 C (99.5 F), blood pressure is 108/66 mm Hg, and pulse is 102/min. Orthostatic changes are present and oral mucosa are dry. The lungs are clear on auscultation and heart sounds are normal. The abdomen is soft with mild generalized tenderness, and no lower extremity edema is present. There is focal tenderness of the mid thoracic vertebrae with no focal neurologic deficit. Laboratory results are as follows: In addition to intravenous fluids, which of the following is the most appropriate management of this patient?

Question

A 68-year-old woman comes to the emergency department due to severe generalized weakness and dizziness.  She has not fallen or lost consciousness.  The patient reports no chest pain, dyspnea, cough, or diarrhea; however, she has had worsening fatigue, nausea, and anorexia for the past 3 weeks.  The patient has a history of breast cancer treated with surgery and chemotherapy 5 years ago but was found to have a vertebral metastatic lesion during evaluation of back pain a month ago.  Radiation therapy and systemic chemotherapy are planned, but she has not received treatment yet.  The patient has no other medical conditions, and the only prescribed medication is opioid analgesic as needed.  Temperature is 37.5 C (99.5 F), blood pressure is 108/66 mm Hg, and pulse is 102/min.  Orthostatic changes are present and oral mucosa are dry.  The lungs are clear on auscultation and heart sounds are normal.  The abdomen is soft with mild generalized tenderness, and no lower extremity edema is present.  There is focal tenderness of the mid thoracic vertebrae with no focal neurologic deficit.  Laboratory results are as follows:  In addition to intravenous fluids, which of the following is the most appropriate management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d40a_3b7f_bc81_25954490a521_MD0003_00 This patient has evidence of primary adrenal insufficiency (AI), likely due to metastatic breast cancer. The adrenal glands are a common site of metastatic cancer spread, especially for primary tumors of the lung, breast, kidney, and skin (ie, melanoma). With extensive involvement of the bilateral adrenal glands, primary AI can occur, with manifestations reflecting adrenocortical destruction: adrenocortical Reduced aldosterone production causes renal sodium wasting and potassium retention, leading to hypovolemia, hypotension/orthostasis, and hyperkalemia. The hypovolemia provides nonosmotic stimulus for antidiuretic hormone (ADH) secretion, with consequent water retention and hyponatremia. Reduced cortisol production contributes to hypotension (cortisol helps enhance vascular tone), causes constitutional symptoms (eg, fatigue, anorexia), can trigger hypoglycemia, and may lead to eosinophilia (by reducing eosinophil migration into the tissues). Because cortisol normally inhibits ADH secretion, the reduced cortisol levels also contribute to hyponatremia. Although low morning cortisol levels can suggest AI, the diagnosis is made by cosyntropin stimulation testing. Cosyntropin is a synthetic form of ACTH; absence of the expected increase in cortisol levels following cosyntropin administration reflects adrenocortical destruction. The test is usually performed in the morning, when cortisol responses in healthy individuals are normally the most pronounced. Measuring basal ACTH (before cosyntropin injection) can help differentiate primary AI (high basal ACTH) from AI due to hypothalamic-pituitary deficiency (low basal ACTH). (Choice A) Appetite stimulants (eg, megesterol) and nutritional supplements may be helpful for malignancy-related anorexia. However, this patient's electrolyte abnormalities are consistent with primary AI, which is likely causing much of her anorexia. (Choice B) Blood cultures and empiric antibiotics may be appropriate for suspected vertebral osteomyelitis, which can cause fatigue and focal vertebral tenderness. However, fever and leukocytosis would be expected, and this patient's vertebral tenderness is most likely due to known vertebral metastatic disease. (Choice D) Overtreatment with opioid pain medications (eg, oxycodone) may cause confusion and malaise; however, it would not explain this patient's laboratory findings. (Choice E) Percutaneous gastrostomy tube placement is indicated in patients with severe dysphagia or those who are unable to maintain adequate nutrition with oral intake alone. It would not be appropriate in this patient as her anorexia may improve with treatment of primary AI. Educational objective: The adrenal glands are a common site of metastatic cancer spread, and extensive metastatic involvement can lead to primary adrenal insufficiency (PAI). Clinical manifestations of PAI include hypotension/orthostasis, hyponatremia, hyperkalemia, and hypoglycemia. Diagnosis is made by cosyntropin stimulation testing.

A 68-Year-Old Woman Comes to the Emergency Department Due to Severe