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  #1  
Old 10-18-2011
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Question Hormonal therapy after brain surgery!

A 50-year-old woman is brought to the emergency department by a friend in the evening. Two days ago the woman began having symptoms of a urinary tract infection, for which she saw a doctor and began taking antibiotics yesterday. However, since then she has reported body aches, fatigue, and intolerance to cold; she’d had these for several months but they have recently worsened. The only medical history known by the friend is an episode over a year ago when the patient had nipple discharge and subsequently had surgery for a tumor in her brain; she was on some medications but stopped them when she ran out. The patient is able to corroborate some of this history but appears slightly confused and lethargic. She is thin and pale-appearing. She is afebrile, blood pressure is 105/65 mm Hg, pulse is 104/min, and respirations are 16/min. Physical examination shows dry mucous membranes, nonpitting edema of the hands and lower extremities, and minimal body hair. Reflexes are present but show slightly delayed relaxation. She has no evidence of hyperpigmentation. Laboratory studies show a sodium of 122 mEq/L, potassium of 3.6 mEq/L, chloride of 87 mEq/L, and bicarbonate of 27 mEq/L. BUN and creatinine are normal. Serum glucose is 80 mg/dL. Her leukocyte count is 14,000/mm3, and her hematocrit and platelets are normal. Blood cultures are sent, and intravenous fluids and antibiotics are administered. An ACTH stimulation test is planned for the morning. In addition, which of the following should be the next added therapy?

A. Dexamethasone
B. Fludrocortisone
C. Glucose
D. Hydrocortisone
E. Levothyroxine
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Old 10-18-2011
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i m with e,,,although the fact that she is thin confuses me
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Old 10-18-2011
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Answer is B.

She has Addison's disease. Fludrocortisone has a significant mineralocorticoid activity that should help her with the electolyte imbalances hyponatremia and also increase her blood pressure.

She previously had what looked liked a prolactinoma, tumor was removed which affected ACTH production thus the hypocortisolism
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Old 10-19-2011
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B. Fludrocortisone
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I'm Predictable In The Unpredictable Future !
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Old 10-19-2011
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Correct Answer Answer

The correct answer is A. The most common causes of hypopituitarism usually relate to a neoplasm or a complication of a neoplasm, such as subsequent surgery or radiation. The manifestations depend on several factors, including the patientís age, the cell types affected, and the severity of each deficiency. Possible problems include secondary adrenal insufficiency, central hypothyroidism, gonadatropin deficiency, growth hormone deficiency, and prolactin deficiency. This patient is at risk for developing any of these complications after her surgery. The most dangerous immediate problem is acute adrenal insufficiency, and thus glucocorticoids are the treatment of choice. Because cortisol levels and response to ACTH stimulation may need to be tested, dexamethasone is preferable; hydrocortisone
(choice D) is converted in the body to cortisol and would interfere with cortisol measurement. Hypothyroidism can be one of the manifestations of hypopituitarism; some of this patientís manifestations are likely due to hypothyroidism. Even in severe cases of hypothyroidism, however, if there is any suspicion for adrenal insufficiency glucocorticoids should be administered first because thyroid replacement (choice E) can cause exacerbation of adrenal insufficiency.
Patients with primary adrenal insufficiency often manifest salt craving, hyperkalemia, a metabolic acidosis, and, in severe cases, cardiovascular collapse, and patients with secondary adrenal insufficiency have a deficiency of ACTH leading to decreased cortisol secretion that does not usually affect aldosterone. Thus, mineralocorticoid replacement, such as fludrocortisone (choice B), is usually not needed. Even in cases of primary adrenal insufficiency, the salt-retaining and potassium-lowering effects often take days so mineralocorticoid replacement is not the first drug given.
Glucose infusion (choice C) is incorrect because although this patientís glucose is probably inappropriately low, given her current state and need to be watched closely, it is within the normal range and will improve with steroid administration.
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Old 10-19-2011
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I checked a couple of sources and they all recommend to start with hydrocortisone. The reason why fludrocortisone is not the best choice makes sense to me though.

Can you please provide some links on why dexamethasone is preferable?

Thanks
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Question mentions that ACTH stimulation test is to be done in morning. Now if we give Hydrocortisone than it will ruin the test results and hence Dexamethasone should be used here. Otherwise Hydrocortisone/Dexamethasone both are good for treatment.

http://emedicine.medscape.com/article/765753-treatment
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Old 11-06-2011
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This good Q, Dexamethasone is a potent synthetic member of the glucocorticoid class of steroid drugs, why then dexa is not going to ruin ACTH stimulation tes?
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that is the same question i was about to ask.. hydrocortisone seems a more favorable answer to me since it has equal glucocorticoid and mineralocorticoid action.
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Old 11-06-2011
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Based on studies Dexamethasone is the least to have a crossreactivity woth cortisol assay. Here's the site to read the article about this

http://www.clinlabnavigator.com/Test...syntropin.html
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