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  #1  
Old 06-08-2012
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Question Hypotension and Confusion in Anticoagulated Patient?

A 51-year-old man is admitted to the hospital with the acute onset of hypotension, generalized weakness, and confusion. He has experienced progressive shortness of breath over the past two years, which occurs now even on minimal exertion. He has a history of multiple transient ischemic attacks (TIAs), a pulmonary embolus last year, and a chronic deep venous thrombosis (DVT). Evaluation for a hypercoagulable state was unrevealing. He has been on coumadin over the last year. His temperature is 100.2 F, blood pressure is 80/20 mm Hg, and pulse is 104/min. His skin is hyperpigmented. There is jugular venous distention and small testicles. He has a systolic murmur heard over the third to fourth intercostal space, along the left sternal border. On lung auscultation, there are crackles bilaterally, and the liver edge is palpable 3 cm below the right costal margin. There is bilateral leg edema, and the stool is guaiac-positive. His white cell count is 16,800/mm3. Other laboratory tests show: sodium 122 mEq/L, potassium 5.5 mEq/L, glucose 48 mg/dL, calcium 11.3 mg/dL, BUN 88 mg/dL, and creatinine 2.2 mg/dL. His prothrombin time is 34 seconds, INR is 4.5, and partial thromboplastin time is 64 seconds. The albumin level is 1.2 g/dL, and hematocrit is28%. What would be most important initial step in the management of this patient?
(A) Order blood transfusion and start normal saline
(B) The cosyntropin stimulation test
(C) Send blood for cortisol and treat with hydrocortisone and normal saline
(D) Send blood and sputum cultures and start broad-spectrum antibiotics
(E) Vitamin K and fresh frozen plasma

by the way, what is his diagnosis
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Old 06-09-2012
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I will go with C
This pt has anticoagulant overdose that led to bleeding into adrenal leading to adrenal crisis. Pt also hv liver failure? I dont know the cause of this but this will also add to hemorrhage
After steroid and NS this pt should also receive FFP
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Old 06-09-2012
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(C) Send blood for cortisol and treat with hydrocortisone and normal saline
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Old 06-09-2012
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Quote:
Originally Posted by bisho View Post
I will go with C
This pt has anticoagulant overdose that led to bleeding into adrenal leading to adrenal crisis. Pt also hv liver failure? I dont know the cause of this but this will also add to hemorrhage
After steroid and NS this pt should also receive FFP


why not FFP first ? man, INR is 4.5 !
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Old 06-09-2012
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Most important step if u hv adrenal crisis is to substitute steroid rather than treating the cause
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Old 06-09-2012
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Adrenal HGE leading to acute adrenal crisis
answer is C
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Endocrinology-, Internal-Medicine-, Step-2-Questions

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