Adrenal Case: 68-year-old Man with Nausea, Lightheadedness, Back and Abdominal Pain

by Michael Lazarus, MD

My Notes
  • Required.
Save Cancel
    Learning Material 2
    • PDF
      Slides 01-02-02 Adrenal Pituitary.pdf
    • PDF
      Download Lecture Overview
    Report mistake

    00:01 Let's go on to another case.

    00:03 A 68-year-old man is evaluated in the hospital for several hours of nausea, lightheadedness, and abdominal pain.

    00:10 He underwent a laparoscopic cholecystectomy four days ago.

    00:14 He had been doing well postoperatively until now.

    00:17 Medical history is significant only for gouts.

    00:20 Medications are prophylactic dose unfractionated heparin and as needed oxycodone.

    00:27 On physical examination, his temperature is 37.2 degrees Celsius.

    00:31 Blood pressure is 80/50.

    00:33 Pulse rate is 110 beats per minute with a respiration rate of 18.

    00:39 His BMI is 26.

    00:41 Examination of the abdomen shows a clean and dry surgical wound.

    00:46 Cardiac exam reveals regular tachycardia.

    00:49 There is no pain with palpation of the abdomen or lower back.

    00:54 His skin pigmentation is normal.

    00:58 There is a low serum sodium of 130 mEq/L.

    01:03 Potassium is 6.0 mEq/L. Random cortisol is less than 2 μg/dL.

    01:12 What is the most likely diagnosis? Here we have a patient presenting with fairly nonspecific features after surgery but does manifest with postoperative hypotension as well as abdominal pain and nausea.

    01:30 He has a low serum cortisol.

    01:33 This, in conjunction with the low blood pressure, gives us the most likely diagnosis of adrenal insufficiency.

    01:43 When a stem in a USMLE CK question mentions the word skin pigmentation, either in the positive or the negative, always consider adrenal insufficiency.

    01:55 Primary adrenal insufficiency does manifest with hyperpigmentation within the palmar creases of the hands or in the buccal mucosa or the mouth.

    02:05 This, when found, is very specific for a diagnosis of Addison’s disease.

    02:11 The absence of skin pigmentation certainly doesn't rule out the diagnosis as in this case.

    02:17 The labs are typical for low cortisol state, particularly the electrolytes where you see a low sodium and a high normal potassium as well as a low cortisol.

    02:30 The conclusion here is this patient has adrenal insufficiency probably caused by his use of unfractionated heparin that has caused bilateral adrenal hemorrhage.

    02:41 The next test to confirm the low cortisol is to perform a cosyntropin stimulation test.

    02:47 This patient's primary adrenal failure is likely due to the bilateral adrenal hemorrhage.

    02:53 Acute onset of nausea, lightheadedness, back and abdominal pain as well as hypotension are usually consistent features of acute adrenal failure.

    03:03 Lab studies show hyponatremia, hyperkalemia, and hypocortisolemia which are also consistent with the diagnosis.

    03:11 The risk factors for adrenal hemorrhage include anticoagulant therapy, which may occur with treatment levels as well as levels within the therapeutic range, also the post-operative state, abnormalities of hemostasis such as heparin-induced thrombocytopenia or the antiphospholipid antibody syndrome, and in the presence of sepsis.

    03:33 Failure to identify acute adrenal failure in a timely manner may lead to cardiovascular collapse.

    03:39 Adrenal hemorrhage can often be visualized on abdominal CT scanning.

    03:45 That would be indicated in the management of this patient.

    03:48 Treatment of acute adrenal failure with stress-dose glucocorticoids is indicated.

    03:53 Hydrocortisone in a range of 50-100 mg intravenously every six to eight hours is recommended.

    04:02 Further supportive care with intravenous fluids and vasopressors may be needed if the patient's blood pressure does not respond.

    About the Lecture

    The lecture Adrenal Case: 68-year-old Man with Nausea, Lightheadedness, Back and Abdominal Pain by Michael Lazarus, MD is from the course Adrenal Gland Disorders. It contains the following chapters:

    • Adrenal Gland Case: 68-year-old Man with Nausea and Abdominal Pain
    • Adrenal Insufficiency

    Included Quiz Questions

    1. Adrenal insufficiency
    2. Pituitary ischemia
    3. Hypothalamic infarction
    4. Autoimmune polyendocrine syndrome
    1. Morning (8AM) cortisol measurement and cosyntropin stimulation test
    2. Repeat potassium level
    3. MRI of the brain
    4. CT of the chest
    5. Late-night serum cortisol level

    Author of lecture Adrenal Case: 68-year-old Man with Nausea, Lightheadedness, Back and Abdominal Pain

     Michael Lazarus, MD

    Michael Lazarus, MD

    Customer reviews

    5,0 of 5 stars
    5 Stars
    4 Stars
    3 Stars
    2 Stars
    1  Star