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A 68 year old lady presents to the emergency department after 5 days of vomiting. She is now so lethargic she cannot get out of bed and is no longer able to walk. She has not had fevers, diarrhoea or abdominal pain.
Her past medical history includes polymyalgia rheumatica and osteoporosis.
Her medications are: aspirin 100mg mane, prednisone 12mg mane, alendronate 10mg mane.
She is pale, drowsy and generally weak, but with no focal neurological deficits.
She is peripherally cool, with dry mucous membranes. Her abdomen is soft, with no focal tenderness.
On examination her vitals are:
T 35.9
HR 120
BP 75/45
RR 24
O2 sats 98% RA
Despite an initial 1000ml N.Saline fluid bolus, her systolic BP remains in the 70s.
Initial bedside VBG:
pH 7.28
Na 123
K 3.5
Cl 100
HCO3 16
Glu 2.2
Her past medical history includes polymyalgia rheumatica and osteoporosis.
Her medications are: aspirin 100mg mane, prednisone 12mg mane, alendronate 10mg mane.
She is pale, drowsy and generally weak, but with no focal neurological deficits.
She is peripherally cool, with dry mucous membranes. Her abdomen is soft, with no focal tenderness.
On examination her vitals are:
T 35.9
HR 120
BP 75/45
RR 24
O2 sats 98% RA
Despite an initial 1000ml N.Saline fluid bolus, her systolic BP remains in the 70s.
Initial bedside VBG:
pH 7.28
Na 123
K 3.5
Cl 100
HCO3 16
Glu 2.2
1. State the most likely diagnosis and give your rationale (3 marks)
Diagnosis: Addisonian crisis
Rationale:
- Known steroid dependence/steroid, with concurrent illness
- Consistent presentation: refractory shock, hypoglycaemia, NAGMA, hyponatremia
Rationale:
- Known steroid dependence/steroid, with concurrent illness
- Consistent presentation: refractory shock, hypoglycaemia, NAGMA, hyponatremia
2. List 3 components of her VBG that aids in confirming your diagnosis (3 marks)
Anion Gap: Na-Cl-HCO3 = 123-100-16 = 7 = NAGMA
Critical hypoglycaemia
Moderate hyponatremia
Critical hypoglycaemia
Moderate hyponatremia
3. List 5 key treatments that you would provide in this case (5 marks)
Correct hypoglycaemia: 50 ml 50% dextrose IV
IV hydrocortisone/dexamethasone: 100mg IV hydrocortisone OR 4-8mg IV
dexamethasone
IV fluids: Further 1L N Saline bolus IV then commence inotropes if SBP <100mmHg
Inotropes: Noradrenaline 5-10 mcg/min IV infusion aim SBP >100mmHg/MAP>65 or
improved end organ perfusion
Broad spectrum antibiotics for sepsis: (marks for anything reasonable to cover either
sepsis ? source or intra-abdominal sepsis): flucloxacillin 2g IV PLUS gentamicin 7mg/kg
IV, or piptaz 4.5g IV
IV hydrocortisone/dexamethasone: 100mg IV hydrocortisone OR 4-8mg IV
dexamethasone
IV fluids: Further 1L N Saline bolus IV then commence inotropes if SBP <100mmHg
Inotropes: Noradrenaline 5-10 mcg/min IV infusion aim SBP >100mmHg/MAP>65 or
improved end organ perfusion
Broad spectrum antibiotics for sepsis: (marks for anything reasonable to cover either
sepsis ? source or intra-abdominal sepsis): flucloxacillin 2g IV PLUS gentamicin 7mg/kg
IV, or piptaz 4.5g IV
4. List one intervention that may prevent similar episodes for this patient in the future (1 mark)
Steroids should be increased with physiologic stress (sick day management) – doubling
or tripling PO steroids.
or tripling PO steroids.
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