Regarding the diagnosis of adrenal crisis, which ONE of the following statements is TRUE?
Answer: C: Adrenal crisis is a life-threatening emergency that occurs in patients with primary as well as secondary adrenal insufficiency. Features include:
In adrenal crisis there is a severe exacerbation of adrenal insufficiency due to increased physiological demand or decreased supply of cortisol. In vulnerable patients any major stress such as intercurrent illness, sepsis, surgery, major trauma, acute myocardial infarction or acute complete/partial withdrawal of long-term steroids may provoke the crisis. Profound hypoglycaemia is not normally a significant issue in this condition.
References:
Regarding the management of adrenal crisis, which ONE of the following is TRUE?
Answer: A: In suspected adrenal crisis, intravenous fluid resuscitation should be commenced rapidly to correct fluid loss and hypotension. Both intravenous hydrocortisone and dexamethasone will provide effective steroid replacement, and hydrocortisone is considered the drug of choice because it has both glucocorticoid and mineralocorticoid actions. However, hydrocortisone interferes with cortisol assay in the ACTH stimulation test (short synacthen test) and therefore intravenous dexamethasone may be used for initial treatment if diagnostic testing is planned. Fluid resuscitation should be commenced immediately. Crystalloid containing both normal saline and 5% dextrose is recommended to treat associated hyponatraemia and hypoglycaemia. Specific mineralocorticoid (fludrocortisone) therapy is not usually required if adequate fluid and sodium replacement is delivered, and the patient receives hydrocortisone. Patients unresponsive to fluid resuscitation may require vasopressor treatment to normalize their haemodynamic status.
An adult patient presents to the ED with sepsis and hypotension, secondary to right lower lobe pneumonia. He is on immunosuppressant therapy, including long-term prednisolone, as treatment for a previous liver transplant.
Which ONE of the following is MOST appropriate in the initial management of this patient?
Answer: D: This patient has been treated with long-term steroids and hence there is a high risk of developing adrenal crisis as a result of stress caused by sepsis. As the patient is in septic shock with hypotension, intravenous hydrocortisone may not be adequate to provide adequate mineralocorticoid activity, although it provides adequate glucocorticoid activity. Until shock resolves, both hydrocortisone and fludrocortisone is recommended to prevent adrenal crisis. If the patient is not in shock, intravenous hydrocortisone alone is adequate to provide both glucocorticoid and mineralocorticoid cover. In non-shock situations, intravenous dexamethasone, which mainly provides glucocorticoid cover, can also be used.
Reference:
Regarding ocular examination findings in thyroid disease, which ONE of the following statements is TRUE?
Answer: C: Lid lag, lid retraction and proptosis (exophthalmos) are part of thyroid ophthalmopathy and all seen in Graves’ autoimmune thyroid disease. Lid lag (von Graefe’s sign) is a delay in downward movement of the upper eyelid following the downward-moving iris on directing gaze inferiorly, exposing the sclera above the iris. It may resolve with treatment of the underlying endocrine disorder. Lid retraction (hyperthyroid stare or Dalrymple’s sign) is due to retraction of the upper eyelid more than normal, exposing the globe above the iris. Proptosis due to chronic inflammation and swelling of retro-orbital tissues may precede or succeed the appearance of thyroid dysfunction. Lid retraction and proptosis may both continue to deteriorate despite correcting the hormone imbalance. Tarsorrhaphy may be indicated in thyroid ophthalmopathy to protect the cornea from drying and ulceration.
In considering Graves’ disease, which ONE of the following statements is TRUE?
Answer: B: Patients may present acutely with thyrotoxic periodic paralysis. Hypokalaemia is generally present during these attacks, which may be recurrent. The condition is distinct from familial periodic paralysis, a group of inherited disorders.
Graves’ disease is due to a type 2 hypersensitivity reaction, in which IgG antibodies stimulate thyroid cells to produce and release thyroxine. Thyroid ophthalmopathy is due to IgG antibodies provoking a chronic inflammatory cell infiltrate of extraocular muscles. It may predate the onset of clinical hyperthyroidism by several years, or may develop or deteriorate despite successful treatment of the thyroid disorder itself. The development of pretibial myxoedema (pinkish-brown plaques on the shins) is likewise independent of thyroid status.
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