USMLE Forum Archives - USMLE Step 2 CK - IM 47
IM 47
TheOne - 07-14-07 18:17
A 40 years old woman has unexplained fatigue, weight loss, nausea, and diffuse muscle pains over the last 2 months. She has a history of severe asthma for which she has been using an inhaled beta agonist, together with oral prednisone (10 mg/day) that was started early this year. Three months ago her breathing seemed to be getting a lot better, so she decided to stop the prednisone because she felt it was making her gain weight. Her temperature is 37.0 C (98.6 F), blood pressure is 95/40 mm Hg, pulse is 110/min, and respirations are 15/min. On physical examination she has a tanned appearance with an otherwise normal skin examination. Her heart is tachycardic and regular without murmurs. Her lungs have a few scattered wheezes. Laboratory studies show:
Na 127 mEq/L
K 5.6 mEq/L
Cl 93 mEq/L
HCO3 17 mEq/L
Glu 166 mg/dL
BUN 35 mg/dL
Cr. 1.0 mg/dL
Adrenocorticotropic hormone: Elevated
Which of the following is the most likely etiology of this patient's condition?
A. Autoimmune
B. Hemorrhagic
C. Iatrogenic
D. Infectious
E. Pituitary
TheOne - 07-14-07 18:17
A 40 years old woman has unexplained fatigue, weight loss, nausea, and diffuse muscle pains over the last 2 months. She has a history of severe asthma for which she has been using an inhaled beta agonist, together with oral prednisone (10 mg/day) that was started early this year. Three months ago her breathing seemed to be getting a lot better, so she decided to stop the prednisone because she felt it was making her gain weight. Her temperature is 37.0 C (98.6 F), blood pressure is 95/40 mm Hg, pulse is 110/min, and respirations are 15/min. On physical examination she has a tanned appearance with an otherwise normal skin examination. Her heart is tachycardic and regular without murmurs. Her lungs have a few scattered wheezes. Laboratory studies show:
Na 127 mEq/L
K 5.6 mEq/L
Cl 93 mEq/L
HCO3 17 mEq/L
Glu 166 mg/dL
BUN 35 mg/dL
Cr. 1.0 mg/dL
Adrenocorticotropic hormone: Elevated
Which of the following is the most likely etiology of this patient's condition?
A. Autoimmune
B. Hemorrhagic
C. Iatrogenic
D. Infectious
E. Pituitary
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#1
Re: IM 47 wendy - 07-17-07 15:43 Iatrogenic...She shouldn't have stopped the prednisone just like that :huh: :-)
#5
Re: IM 47
TheOne - 08-01-07 16:05 The correct answer is C. This patient has adrenal insufficiency. Clues to the diagnosis are nonspecific findings such as fatigue, weight loss, and muscle aches. Laboratory abnormalities such as hypoglycemia, hyponatremia, and hyperkalemia are seen. Hyperpigmentation of the skin is seen because melanocyte-stimulating hormone is released along with adrenocorticotropic hormone. The most common reason for patients to have adrenal insufficiency is prolonged steroid use (and therefore the answer is iatrogenic). Our patient has a history of asthma that was controlled with prednisone. She gives a history of discontinuing the steroids before the onset of her symptoms. This should be a clue in our patient's diagnosis.
#6
Re: IM 47 bingousmle - 06-20-10 07:47 this patient has landed in an acute adrenal insufficiency sue to the withdrawal of steroids which is explained by the elevated ACTH levels... give her steroids and get a cosyntropin stimlation test done
#7
Re: IM 47 babbu5508 - 06-20-10 13:34 C. Iatrogenic..the patient has developed hypoadrenalism due to abrupt stoppage of corticosteroids...shown by raised ACTH levels,hyponatremia,hyperkalemia etc.
#9
Re: IM 47 bingousmle - 06-30-10 18:04 a sensitive test that can be performed in this patient is early morning measurement of glucocorticoids in urine.. why is cosyntropin preferred?
#10
Re: IM 47 babbu5508 - 07-10-10 03:19 C. Iatrogenic...adrenal insufficiency due to abrupt stoppage of using corticosteroids...resulting in pigmentation,hyperkalemia,hyponatremia.
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