A 54 year old female

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

Patient was admitted for ACTH stimulation test.

9 years ago -she has  h/o cough and diagnosed with pulmonary kochs used ATT for 6 months associated with joints pains .

8 years ago-  she has h/o increased joint pains - polyarthritis - prescribed with steroids by local doctor and was adviced to taper and stop .But as she stopped using steroids ,the pains increased,so she kept on using steroids continuously for 6-7 years on and off , sometimes daily.

15 years ago,she went for routine check up and diagnosed with HTN and started on medication.

7 years ago ,h/o  increased joint pains with  facial puffiness and  started using thyronorm in view of hypothyroidism

 September 2020 came to our hospital with chief complaints of neck pain ,headache and was admitted and treated for uncontrolled hypertension discharged on tab clinidipine 10 MG bd tab Losartan 50 MG Od

 one year ago, patient went to USA and stop taking steroids continuously for 15 days . complains of giddiness, vomitings, pain abdomen, headache and was admitted in USA found to have sodium 110 ,hypotension ,adrenal insufficiency and findings concerning for pan hypopituitarism ( labs consistent with central hypogonadism , central hypothyroid ,adrenal insufficiency and long-standing usage of chlorthalidone led to hyponatraemia was advised to follow up with endocrinologist and  MRI pituitary. and was discharged after sodium correction ,started on cortisol and increased levothyroxine dose to 75MG

IGF-1-<15U decrease 

Prolactin 20.43(4.8-23),underwent MRI brain which showed empty sella syndrome 

Pt is admitted for ACTH stimulation test.Now on T.Hirone 5mg

- Menopause attained 10 years age

- k/c/o HTN since 15 years 

-k/c/o hypothyroidism since 7-8 years

Vitals 

Temp- afebrile

BP-130/90mmhg

PR-89bpm

RR-22cpm

No pallor/icterus/clubbing/ lymphadenopathy


CVS-s1,S2 +

RS- BAE +

P/A - soft ,nontender

CNS- Nad

Investigations

Investigations in USA done at the time of adrenal insufficiency

1.FSH 1.4IU/L(low)

2.LH <0.2IU/L(low)

3.ACTH:18pgm

4.Serum cortisol 13.9(low)

5.Aldosterone <3.0mcg/dl(low)

6.TSh 1.42(low)

7.Free T4 -0.6(low)

8.IGF 1:<15U(low)

9.Prolactin:20.43(normal)

10.Serum sodium:110

11.urine osmo 195mosm/l

12.urine Na+ 45mosm/l


Suggesting Central hypogonadism,central hypothyroidism ,secondary adrenal insufficiency and hyponatremia secondary to ?chlorthalidone use for hypertension.

Adviced to review with MRI sella to hospital,and was discharged on tab HISONE 5mg -2.5mg-2.5mg

Lt4 75mch

Tab cinod 10mg bd

Tab met xl

Tab losartan


But patient returned to India and got MRI brain done

-Patient is continuing on tab HISONE 5mg(6am)-2.5mg(12pm)-2.5mg (4pm) and other hypertension, hypothyroidism medications

-Patient is now admitted for ACTH stimulation test as her h/o adrenal insufficiency can be due to empty sella or sudden stoppage of steroids.

Acth stimulation test is planned so as to look if the HPA axis has been recovered as she is on low dose steroids since 1year .

Plan-if HPA axis recovers probably her adrenal crisis was secondary to steroid abuse stoppage,if HPA axis remains suppressed (if serum cortisol levels comes low after ACTH stimulation) - probably her adrenal crisis was due to empty sella

This test is needed to decide if she need life long supplement of steroids or not

Acth stimulation test was done on 25/5/2022- Report awaited 


Patient is not willing for clinical images

Provisional diagnosis:Empty sella syndrome? Chronic steroid abuse admitted for ACTH Stimulation test .k/c/o HTN , Hypothyroidism.

Treatment:

1)Tab.Hisone po/Tid

2)Inj syntropac iv stat 

3)Tab.Thyronorm 75mcg 

4)Tab.clinidipine 10mg  po/bd

5)Tab.Metaprolol 50mg 

6) Tab.losartan 50mg

7) Inj Hydrocort 100mg sos


 



















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