NCLEX : Identifying Endocrine Conditions
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Example Question #1223 : Nclex
You are the nurse taking care of a patient hospitalized for two months for sepsis. The patient had been receiving 40 mg of prednisone daily for the last two weeks for airway inflammation, and now, for the last three days, given symptomatic improvement, his physician lowers his prednisone dose to 5 mg daily. Today, you assess the patient and he is lethargic and hypotensive, with a serum glucose of 52 and serum sodium of 131. Which of the following is the most likely diagnosis?
Adrenal insufficiency
Hyperaldosteronism
Conn's Syndrome
Surreptitious insulin use
Exogenous testosterone use
Adrenal insufficiency
The correct answer is "Adrenal insufficiency." This answer is correct because in this patient's case, he had been on a prolonged course of a high dose of prednisone, a corticosteroid. When patients are on prolonged courses, and/or high doses of corticosteroids, this can cause a negative feedback cycle on the body's own intrinsic production of corticosteroids. As a result, high doses of exogenous corticosteroids, or prolonged courses of any dose of exogenous steroids should not be abruptly stopped, as the body's own intrinsic steroid production will not yet have recovered, and therefore, the patient will exhibit signs of adrenal insufficiency. In this patient's case, while the physician does not completely eliminate the patient's exogenous steroid dose, he tapers the dose way too abruptly, from 40 mg to 5 mg, which dose not allow the body's own corticosteroid production to recover in time to meet the body's needs. Thus, the patient exhibits signs of adrenal insufficiency including lethargy, hypotension, hypoglycemia, and hyponatremia.
Hyperaldosteronism and Conn's Syndrome (primary hyperaldosteronism) are incorrect as these are the opposite of what is observed in this patient. In a patient with hyperaldosteronism, the patient would likely be anxious and/or have high energy, would be hypertensive, and hypernatremic, as the sodium/potassium ATPase's activity would be upregulated in the setting of excess aldosterone.
Exogenous testosterone use would likely also cause increased anxiety/energy and hypertension, rather than lethargy and hypotension, as in this patient.
Surreptitious insulin use could explain lethargy, hypotension, and hypoglycemia, but would likely cause hypernatremia rather than hyponatremia, as insulin upregulates the activity of the sodium/potassium ATPase, which would increase rather than decrease serum sodium.
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