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  #1  
Old 06-19-2011
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Question 28 y/o with urinary sepsis and hypotension

A 28-year-old woman is admitted with suspected urinary sepsis (temperature 40.2°C, BP 84/50, pulse 128). She had a massive haemorrhage following the birth of her only child when she was aged 24; since then she has had no periods. Her partner says that she has been progressively listless and depressed for at least two years. There is left loin tenderness and she has no pubic or axillary hair. Which of the following would be most appropriate?

A) Amoxicillin
B) Hydrocortisone
C) Pelvic examination
D) Follicle-stimulating hormone + Luteinizing hormone
E) Triiodothyronine
F) Progesterone + Estrogen
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  #2  
Old 06-19-2011
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I think she had a adrenal infarct, so you need to give supplemental corticosteriods...

B) Hydrocortisone..
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  #3  
Old 06-19-2011
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Quote:
Originally Posted by patelMD View Post
I think she had a adrenal infarct, so you need to give supplemental corticosteriods...

B) Hydrocortisone..
adrenal infarct...why?
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Old 06-19-2011
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because, she had a massive hemorrhage!
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Old 06-19-2011
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Quote:
Originally Posted by dr.Irina View Post
becose,she had a massive haemorrhage!
"massive haemorrhage following the birth of her only child"
...I don't think the adrenal gland is the problem here
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Old 06-19-2011
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  1. Quote:
    Originally Posted by bebix View Post
    Adrenal Infarct.. why 1. massive haemorrhage following the birth of her only child when she was aged 24;
  2. since then she has had no periods.
  3. Her partner says that she has been progressively listless and depressed for at least two years
  4. she has no pubic or axillary hair


I think those are the reasons........

woops I meant Pituitary lol... darn it.. today is an off day

I forgot what this was called..
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  #7  
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Quote:
Originally Posted by patelMD View Post


I think those are the reasons........

woops I meant Pituitary lol... darn it.. today is an off day

I forgot what this was called..
Ok, now we are talking, hahaha
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  #8  
Old 06-19-2011
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Sheehan’s syndrome!
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Quote:
Originally Posted by bebix View Post
Sheehan’s syndrome!
Thats it.. haha thanks!
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  #10  
Old 06-19-2011
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so is it D????
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Old 06-19-2011
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Quote:
Originally Posted by earthpole View Post
so is it D????
the correct answer is B) Hydrocortisone

The history suggests Sheehan’s syndrome with superimposed acute pyelonephritis. In addition to i.v. antibiotics she should be treated urgently with i.v. hydrocortisone since the risk of adrenal insufficiency.
Unlike glucocorticosteroid replacement, replacement of sex hormones and thyroid hormone is less urgent and should wait investigation.
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  #12  
Old 06-19-2011
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A) Amoxicillin

We can't ignore the fact that she is suspected of having sepsis. If she has an infection (which we are led to believe), then we have to start antibiotics.

We can take care of the endocrine problem after we treat the infection.
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  #13  
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Quote:
Originally Posted by bebix View Post
the correct answer is B) Hydrocortisone

The history suggests Sheehan’s syndrome with superimposed acute pyelonephritis. In addition to i.v. antibiotics she should be treated urgently with i.v. hydrocortisone since the risk of adrenal insufficiency.
Unlike glucocorticosteroid replacement, replacement of sex hormones and thyroid hormone is less urgent and should wait investigation.
Hmm, why not amoxicillin?
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  #14  
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Quote:
Originally Posted by apx85 View Post
Hmm, why not amoxicillin?
amoxicillin p.o.?
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Quote:
Originally Posted by apx85 View Post
A) Amoxicillin

We can't ignore the fact that she is suspected of having sepsis. If she has an infection (which we are led to believe), then we have to start antibiotics.

We can take care of the endocrine problem after we treat the infection.
But endocrine is more important, she has no corticosteriod function, which means no cortisol or aldosterone... so she can become volume depleted and hypoglycemic aswell.. it would be pretty hard to administer drugs to a patient when they are volume depleted.. I think thats my reasoning.

Even if you give IV fluids, there will be alot of fluid wasting.. so better to treat that problem first, then tackle sepsis..
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Quote:
Originally Posted by patelMD View Post
But endocrine is more important, she has no corticosteriod function, which means no cortisol or aldosterone... so she can become volume depleted and hypoglycemic aswell.. it would be pretty hard to administer drugs to a patient when they are volume depleted.. I think thats my reasoning.

Even if you give IV fluids, there will be alot of fluid wasting.. so better to treat that problem first, then tackle sepsis..
if you have sepsis + adrenal insufficiency...
- volume +++
- i.v. antibiotics
- glucocorticosteroid
and pray

so, in this question, the best answer is B)...

.
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  #17  
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Quote:
Originally Posted by bebix View Post
amoxicillin p.o.?
I guess this just shows my lack of clinical experience

I struggle with endocrine though, not my best subject
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  #18  
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Patients with sheehan syndrome also require lifelong Hormone replacement..
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  #19  
Old 06-20-2011
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it`s sheehan`s syndrome i think so
answer is FSH&LH relacement
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  #20  
Old 06-20-2011
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i was also thinking of hydrocortisone eventhough Sheehan's didnt strike me...
also how can we justify using steoids in a suspected sepsis?? wouldnt it flare up the infection....???
probably pt s gonna die of sepsis or of adrenal insufficiency....
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  #21  
Old 06-20-2011
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Quote:
Originally Posted by bebix View Post
if you have sepsis + adrenal insufficiency...
- volume +++
- i.v. antibiotics
- glucocorticosteroid
and pray

so, in this question, the best answer is B)...

.
u re absolutely rite we give low dose steroid to help pt with adrenal insufficiency tht wud reverse the shock but i wud like to ask one thing tht wt i ve read this one concept is still controversial ? ive no idea if currently such regime is being used. i wud like to knw is it imp to ve an idea about clinical knowledge regarding emergency managements of various problems like DKA?? as an example
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Quote:
Originally Posted by drnirajmavani View Post
i was also thinking of hydrocortisone eventhough Sheehan's didnt strike me...
also how can we justify using steoids in a suspected sepsis?? wouldnt it flare up the infection....???
probably pt s gonna die of sepsis or of adrenal insufficiency....
@drnirajmavani...here is a very interesting paper about Corticosteroids in the treatment of severe sepsis and septic shock in adults (JAMA, Annane 2009)
Attached Files
File Type: pdf JAMA-2009-Annane.pdf (240.3 KB)
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  #23  
Old 06-20-2011
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Like Bebex said, in the real situation, the treatment will be antibiotics + cortisone + IV .

The pt had sheehan's for 4 years, it is a chronic situation, may cause crisis during infection.
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  #24  
Old 06-21-2011
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Quote:
Originally Posted by bebix View Post
@drnirajmavani...here is a very interesting paper about Corticosteroids in the treatment of severe sepsis and septic shock in adults (JAMA, Annane 2009)
Hey....can u attach this file again... i think the file is corrupted...i'm nt able to open it properly...i m nt sure others r facing the same probs....thnx
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Old 06-21-2011
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Quote:
Originally Posted by drnirajmavani View Post
Hey....can u attach this file again... i think the file is corrupted...i'm nt able to open it properly...i m nt sure others r facing the same probs....thnx
Today I had the same problem with another pdf file ....anyway, here it is again...please let me know

JAMA-2009-Annane.pdf
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  #26  
Old 06-21-2011
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Quote:
Originally Posted by bebix View Post
Today I had the same problem with another pdf file ....anyway, here it is again...please let me know

Attachment 1587
its still d sam...nt able to open
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  #27  
Old 06-21-2011
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Quote:
Originally Posted by drnirajmavani View Post
its still d sam...nt able to open
weird

how about now?
http://www.divshare.com/download/15148713-a37
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  #28  
Old 06-21-2011
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Quote:
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nope...dis link itself is broken...r u able to open it properly??
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  #29  
Old 06-21-2011
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Quote:
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nope...dis link itself is broken...r u able to open it properly??
broken??? it can't be!!! (that's my own virtual hard drive...I´m paying for that, hahaha)...just send me a pm with your email and sorry about that
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  #30  
Old 06-21-2011
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OMG I had a brain infarct I think, thanks for the qn.
And never gave thought into
1. REPLACE GLUCOCORTICOID FIRST- patel MD good expl
2. THEN worry about sex, thyroid.
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  #31  
Old 06-21-2011
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Guys... I am General Surgeon involved in the process of passing USMLE (IMG).

I congratulate you all guys for the high level of interest and knowledge. Bebix and miss Patho...and many others are truly awesome.
In this case...perhaps due to my experience I felt able to answer even being in the middle of the text. Typic question in order to see if we have clear the concept of what is first or more important. Neither antibiotics nor hormones nor praying will work if we don't pay attention to the main problem: the lack of a good hormonal axis...and the result of being in a chronic low level of steroids needed for thousands of processes.
If you allow me... .. I suggest Hidrocortisone as answer.
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Quote:
Originally Posted by Chemole View Post
Guys... I am General Surgeon involved in the process of passing USMLE (IMG).

I congratulate you all guys for the high level of interest and knowledge. Bebix and miss Patho...and many others are truly awesome.
In this case...perhaps due to my experience I felt able to answer even being in the middle of the text. Typic question in order to see if we have clear the concept of what is first or more important. Neither antibiotics nor hormones nor praying will work if we don't pay attention to the main problem: the lack of a good hormonal axis...and the result of being in a chronic low level of steroids needed for thousands of processes.
If you allow me... .. I suggest Hidrocortisone as answer.
yup, that´s the right answer (and pray, hahaha)
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