Student case

[EMEDPA]

Lady in her early 50s brought in by ambulance. Medics were called for aloc and weakness with n/v for the last week. She is confused, hypotensive, and tachycardic despite 1000 cc of IV fluids from EMS and has not kept any of her meds down for a week. Her fingerstick blood sugar is 285.

Oral Meds: Omeprazole, pepcid, amlodipine, zoloft, colace, metformin, hydrocortisone, zofran, trazadone.

Based on the brief hx provided and the med list you have been given, what is the zebra diagnosis you can not miss in this lady and what med does she need right now?

[EMEDPA]

This is a cool case folks....non-students can chip in now...

[rev ronin]

My initial zebra DDx is lactic acidosis (because hospitalists hate on Metformin for it) and Serotonin syndrome. After refreshing myself, the former looks to fit the facts better.

[EMEDPA]

13 minutes ago, rev ronin said:

My initial zebra DDx is lactic acidosis (because hospitalists hate on Metformin for it) and Serotonin syndrome. After refreshing myself, the former looks to fit the facts better.

Strike one and strike 2. Note the patient has taken no medication for 1 week. 

Which of those meds can you not miss for a week and what is the consequence if you do? 

[Reality Check 2]

Hydrocortisone. She has no stress defense, no cortisol.

Adrenal crisis in action.

Edited June 25, 2023 by Reality Check 2

[EMEDPA]

36 minutes ago, Reality Check 2 said:

Hydrocortisone. She has no stress defense, no cortisol.

Adrenal crisis in action.

Bingo! Addisonian crisis. 

[Reality Check 2]

Sadly, I have a couple of patients who live by their Naturopaths who have put them on hydrocortisone for adrenal “fatigue”. Now the patients are hydrocortisone dependent with no real understanding of their circumstance. They have never been taught about stress dosing or surgery or consequences. They just know they “feel better”.

Knowing exactly what a patient takes, why and from what source is paramount to any encounter but absolute in EMED’s position in ER.