Category: Case Presentations/Quizzes

Hiya! I’m back with another case presentation. Just like case 2, I presented this during my didactics. This format is a bit different than the last one as this case I followed for awhile. Again, at each stop sign, stop and answer the questions. Work on practicing putting your skills to use!

HPI:

61 y/o F presenting with persistent hypoglycemia. EMS initially called to scene for AMS. BS found to be in the 30’s. D50 given en route with improvement of mental status to A&Ox2.  Paperwork from her SNF facility had shown recent metabolic encephalopathy secondary to UTI and persistent hypoglycemia. Patient complains of overall body pain. No other history could be provided in the ED.

Initial VS: 36.7’F, 88 BPM, 15 RR, 128/78 mmHg, 98% on RA

What are your differentials based off of this information? What is moved up on your list? What is moved down? What is crossed off?

What would you like to order to evaluate this patient?

Review your differential diagnosis list. What do you want to order to further evaluate this patient? What do you want to do to treat this patient?

Initial Plan: continuous D10 infusion, accuchecks q4, monitoring.

Day 2: Mental status continued to deteriorate. Became more confused, would wax and wane between A&Ox1 and x2. BP started to slowly drop. lowest BP 93/57mmHg. Endocrine consulted. Cortisol levels, sulfonylurea levels, proinsulin, c-peptide, and insulin levels pending.

Review of records: Patient was recently seen in hospital in June and August with full acute encephalopathy workup including EEG, MRI, CT, LP.  All returned normal.

Day 3: BP ranged from 93/50-108/57. Stopped eating much. Nauseated and vomiting. Became more confused, very drowsy. BG ranged from 90-110’s with D10 infusion. CT abd/pelvis obtained: No adrenal abnormality seen. Small hiatal hernia. Atherosclerotic disease throughout abdominal vasculature. Infrarenal aortic aneurysm: 2.2×2.6cm superiorly and 3.1×3.0 cm inferiorly. Chronic scarring at lung bases.

Dietician and palliative consulted. Persistent hypokalemia at 3.2. Persistent hypomagnesemia at 1.6

Day 4: BG no higher than 130 overnight. BG during the day continued to drop. 2 episodes of BP improving in 140’s systolic, remainder in low 100’s systolic. Eating very little. Nausea and vomiting. Persistent hypokalemia and hypomagnesemia. Poor PO intake.

cortisol level- 0.20 low (baseline)

 Insulin level- normal at 4.7

C-peptide- normal at 0.73.

Pro-insulin and toxicology pending. Awaiting stim test.

Day 5: BG dropped to 60’s with D10 infusion. Additional 250mL bolus given with improvement to 94. Poor oral intake. Nausea and vomiting improved with continued scheduled Zofran. Increased bilateral knee and back pain. BP dropping into the 80’s systolic. Potassium now 3.0 and Mg 1.6 despite repletion earlier. Throughout the day, BG slowly dropping into the 80’s.

Endocrine recommends consider dose of hydrocortisone. Late in the afternoon given dose of Decadron, 4mg IV q8 hours.

Day 6: BG post Decadron jumped to 200’s. D10 infusion stopped. Confused, but more awake now. Poor PO intake.  BP 100-137 systolic. Decadron changed to qd. Hypokalemia 3.2 and hypomagnesemia 1.8.

Day 7:  BG normalizing with less frequent Decadron doses. Stopped eating completely. Re-started on a small amount of IVF. BP stabilizing.

Stim test post ACTH administration: 1.17 –> 5.28–> 7.90

PO fludrocortisone 0.1 mg qd and PO hydrocortisone 15 mg total, 5 mg TID started

Day 8: Continues to have diffuse myalgias and bone pain. Started eating a bit again. No more nausea/vomiting. Confused, but alert. Blood sugar stabilized in the 110’s. Per endocrine, decreased hydrocortisone to 10 mg total, 5 mg BID. Potassium 3.9. Magnesium 2.0. Was discharged back to SNF to continue outpatient endocrine follow up.

After looking through this patient’s chart, what is the diagnosis? Or what are your top diagnoses?

FINAL DIAGNOSIS: Primary adrenal insufficiency

Below are some pictures to help remind you of what the HPA axis is and important information on adrenal glands. I had to completely look this up while taking care of this patient because I hadn’t seen a case like this yet!

Treatment:

We suggest replacement with a short-acting glucocorticoid, hydrocortisone, in two or three divided doses as the glucocorticoid of choice for the management of chronic primary adrenal insufficiency [2]. We suggest using the lowest glucocorticoid dose that relieves symptoms of glucocorticoid deficiency.

Short-acting regimens roughly mimic the normal diurnal rhythm.

 Most patients with primary adrenal insufficiency eventually require mineralocorticoid replacement to prevent sodium loss, intravascular volume depletion, and hyperkalemia. Fludrocortisone (9-alpha-fluorohydrocortisone), a potent synthetic mineralocorticoid, is given orally in a usual dose of 0.1 mg/day. A lower dose (such as 0.05 mg/day) may be sufficient in patients receiving hydrocortisone, which has some mineralocorticoid activity. Rare patients are sufficiently replaced with hydrocortisone alone and become hypertensive, hypokalemic with even 0.05 mg Florinef twice a week.

Below is the flowchart for how to interpret/do the cosytropin stimulation test.

And congrats on going through another case! Until next time, Cheers.

Hello hello!

So I have a few case reports/presentations that I will be posting. I actually have to present cases while I am on Wards/inpatient medicine at least once a month, sometimes more. I have decided to share what I’ve actually presented. These may be easy for you, or they may be challenging.

I challenge you to look at each section, and then think about what this could be and a list of possible differential diagnoses for the new information gathered each time. Stop at each stop sign and see if you can answer the questions below first before moving on.

HPI:

What are you most concerned about? What do you need to rule out first? What will kill the patient and needs to be addressed right away?

Then you can add anything additional such as other common diagnoses, rare diagnoses, etc.

Differentials that my colleagues came up with:

• CVA
• MS
• brain mass
• inflammatory neuro disorder
• MG
• Lambert eaton
• Guillan-barre
• 3^rd nerve palsy
• malingering
• conversion disorder

Vitals in ED: 97.7’F, 61 BPM,  RR 18, 105/55- 172/83, 95% RA

Exam:  ptosis L>R, a fib regular rate. Pacemaker in L upper chest wall. End expiratory wheezing throughout. Neuro: CN II-XII intact. Normal speech. Patellar reflexes 2+. Motor 5/5 BUE and LE. Anxious. Remainder of exam is within normal limits.

Look at your differential list. Is there anything you want to cross off? Anything you want to add?

Do you want to move a diagnosis up or down? What is more likely with this new information?

What type of labs or imaging do you want to order?

LABS/IMAGING:

At this point, we still don’t have an exact diagnosis and patient is not improving. What other special labs or imaging can you order to help you determine what it is?

Additional testing:

COURSE:

Patient remained very anxious and short of breath. Oxygen and hydroxyzine greatly helped her dyspnea symptoms. Dyspnea is likely anxiety given her current situation of being in the hospital and not knowing what is going on, and her increased stress level from her home life.

CONSULTS:

Neurology: Wanted to rule out MG, 3^rd nerve palsy, neuromuscular disorder, GBS. Their testing was added above.

What do you think the diagnosis is?

DIAGNOSIS:

1. Myasthenia Gravis
2. Anxiety secondary to stress

What is the treatment for Myasthenia Gravis?

ANSWER:

Started on Pyridostigmine/Mestinon with improvement of ptosis and weakness symptoms.

So, I hope you enjoyed this layout. This is exactly how we have small learning sessions at my program and I hope you learned something! I also hope you started your journey or at least continued practicing your ability to put all the pieces together.

Until next time. Cheers!