doc_clotaire
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A 52-year-old woman presents to the emergency department with fever,
weakness, and abdominal pain for the past three days. It has been
associated with nausea and three episodes of vomiting. Her husband
states that her temperatures have been as high as 103.5 F and that she
has not been herself lately, appearing confused and lethargic. She has
a history of hypothyroidism and migraine headaches. She appears
lethargic, dehydrated, and is oriented only to person. Her blood
pressure is 75/50 mm Hg, temperature is 102.9 F, and pulse is 108/min.
She has dry oral mucosa and hyperpigmented areas of her skin spread
diffusely over the posterior neck, hands, and knuckles. Rales are
heard over the right lower lung field, and the chest x-ray shows a
right lower lobe infiltrate. The EKG is normal. The patient is placed
on intravenous hydration. Laboratory studies show a white cell count
of 6,300/mm3, and the differential shows 82% neutrophils, 7%
lymphocytes, and 9% eosinophils. The sodium level is 112 mEq/L, with a
potassium of 5.9 mEq/L and a chloride of 92 mEq/L. Bicarbonate level
is 20 mg/dL, and BUN is 32 mg/dL. The creatinine level is normal. The
glucose level is 60 mg/dL, and the urinalysis is normal. What is the
best initial test to diagnose this disorder?
(A) Immediate cortisol and assess ACTH level
(B) Metyrapone stimulation test
(C) Early morning cortisol
(D) A cosyntropin stimulation test
(E) 24-hour urine cortisol
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| new_n_lost
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(D) A cosyntropin stimulation test The Most Conclusive Test for Addison's Disease.
Edited by new_n_lost on 04/05/07 - 01:37 PM
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| jonathon
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Low early morning cortisol and high ACTH is fairly diagnostic. However they didn't state the time so i would go with cosyntropin stimulation test.
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| doc_clotaire
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Like Dr Fischer would say : D is the most common WRONG answer !
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| new_n_lost
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LOL Doc I havent Heard Dr. Fischer Yet SO I Cant Be Blamed. I m preping for Step 1 Sometimes happen to Cross over n see how the weather is ? 
I took it as Addison n Confirmatory Test for it is the Rapid ACTH Stimulation Test =Cortrosyn, cosyntropin, or Synacthen. My Very Limited Knowledge lead me to believe that. My Second Choice Wud AS i m Still Considering it as Addison's as (B) Metyrapone stimulation test.
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| Luckyall
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metyrapone test ?
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| dr.wad
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( A )
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| Justice
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Guys,
the woman is in ER, and the diagnosis must be made immediately... All stimulation tests or 24-hr cortisol take some time and would be useless if you don't know levels of cortisol and ACTH... Clinically this is adrenal deficiency... I go with (A)
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| doc_clotaire
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Answer:
(A) Immediate cortisol and assess ACTH level
Explanation:
In the context of acute adrenal crisis, the most appropriate initial
diagnostic test is to obtain a random cortisol level before initiating
treatment with intravenous hydrocortisone. In a patient who is
hypotensive and hemodynamically unstable, it is inappropriate to
perform any diagnostic maneuvers that require several steps to obtain
a diagnosis. (The metyrapone stimulation and the cosyntropin
stimulation are such tests.) The early-morning cortisol is
diagnostically useful if it is very low, which confirms adrenal
insufficiency, or very high, which excludes adrenal insufficiency. A
24-hour urine for cortisol is a test used to confirm the diagnosis of
the hypersecretion of cortisol, also known as Cushing's syndrome,
which is the opposite of adrenal insufficiency.
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| ram3
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The answer is (A) Immediate cortisol and assess ACTH level this is adrenal insufficiency it presents with wakness fatigue and anorexia also hyperpigmantation due to increased acth level
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| doyoudig
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(A) Immediate cortisol and assess ACTH level
cuz she is in danger of mortality
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| elitoki
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A. cortisol and ACTH should be done immediately.
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| dr in trouble
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A
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| hanwin
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A is the reasonable answer in this situation.
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