22/12/23 – Cases 1, 2, and 3

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1) A 19-year-old girl presents with confusion, lethargy, and abdominal pain. She has complained of nausea, vomiting, and diarrhea for the past few days. Her family history includes type 1 diabetes mellitus in her sister. Her vital signs are temperature 105 °F (40.5 °C), heart rate 149 bpm, blood pressure 70/40 mm Hg, respiratory rate 20 breaths/min, and oxygen saturation 90% on room air. Physical examination shows diffuse skin hyperpigmentation, and mild diffuse abdominal tenderness without rebound. Laboratory test results demonstrate hyponatremia with hyperkalemia and hypoglycemia. She was administered IV dextrose and started on intravenous normal saline. Her blood pressure remains 70/40 mm Hg and vasopressors are started. What is the next step?

1 point

a. Obtain CT of the abdomen

b. Start hydrocortisone 100 mg intravenously

c. Check random cortisol level and wait for the results prior to administration of any steroids

d. Start broad-spectrum antibiotics

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2) An 18-year-old girl presents with generalized malaise and fatigue for the past 2 weeks, decreased appetite, weight loss, alternating diarrhea and constipation, and severe lightheadedness upon standing. Vital signs are blood pressure 80/50 mmHg, heart rate 88 bpm, respiratory rate 18 breaths/min, and temperature 98.9 F (37.2 C). On physical examination, there is pigmentation of the oral mucosa, proximal muscle weakness of the lower extremities, and hyperpigmentation of the palmar creases, knuckles, knees, and elbows. Laboratory tests show potassium of 5.5 mEq/L and sodium of 125 mEq/L. What is the drug of choice for this patient?

1 point

a. Hydrocortisone

b. Dopamine

c. IV calcium

d. IV frusemide

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3) A 17-year-old girl presents with fever and neck rigidity. Her vital signs are blood pressure 96/60 mm Hg, heart rate 122 bpm, respiratory rate 18 breaths/min, and temperature 38.8 °C (101.8 °F). On physical examination, she has neck stiffness with multiple purple skin lesions on the face and the arms. She has a seizure episode in the emergency department. Initial blood tests revealed Na 131, K 5.6, and total CO2 of 17. A lumbar puncture revealed 150 white cells per mm3. She is started on intravenous fluid with broad-spectrum antibiotics. After 2 hours, the patient develops severe abdominal pain and vomits. Blood pressure falls to 90/40. Bedside blood glucose is 60 mg/dL. Which of the following is the next best step in management?

1 point

a. Order clotting studies and prepare 2 units of packed red blood cells

b. Install intracranial pressure monitor and prepare mannitol

c. Begin intravenous hydrocortisone and pressor agent

d. Order CT of the abdomen and prepare for emergency laparotomy

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