MKSAP: 72-year-old man with community-acquired pneumonia

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 72-year-old man is hospitalized for treatment of community-acquired pneumonia. Despite 4 days of treatment with intravenous fluids and antibiotics appropriate for the bacteria cultured from sputum and blood, he remains febrile with mild tachycardia. The patient subsequently develops mild hypotension and is transferred to the intensive care unit. Results of two subsequent blood cultures are negative for bacteria. Medical history is significant for hypertension treated with amlodipine and recurrent osteoarthritis treated with intra-articular injections of triamcinolone several times a year; his last injection occurred 3 months ago. Physical examination shows a pale and anxious man. Temperature is 38.0 °C (100.4 °F), blood pressure is 110/68 mm Hg supine and 102/64 mm Hg sitting, pulse rate is 102/min supine and 124/min sitting, and respiration rate is 21/min; BMI is 33. Lung examination reveals crackles and egophony in the right lower lobe area. Other physical examination findings are unremarkable. Laboratory studies: Albumin 2.7 g/dL (27 g/L) Electrolytes Sodium 139 mEq/L (139 mmol/L) Potassium 3.6 mEq/L (3.6 mmol/L) Chloride 109 mEq/L (109 mmol/L) Bicarbonate 23 mEq/L (23 mmol/L) Cortisol 9.5 µg/dL (262 nmol/L) Thyroid-stimulating hormone Normal Which of the following is the most appropriate next step in management? A: Adrenocorticotropic ...
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: Tags: Conditions Endocrinology Hospital Source Type: blogs