A 34-year old white female is admitted to the intensive care unit with fever, chills, dysuria, diarrhea, marked dizziness, anorexia, nausea, vomiting and abdominal pain for 4 days. On examination, she is ill-appearing, pulse = 98/minute and BP = 100/70 mm/Hg in the supine position. On sitting up, pulse = 110/minute, BP = 80/56 mm/Hg and Temperature = 39C. Skin pigmentation is normal. Abdominal exam shows mild diffuse tenderness.

Sodium = 139 mM/L (n = 136-146), potassium = 4 mM/L (N = 3.5-5.3), CHLORIDE = 96 mM/l (n = 98-108), carbon dioxide = 27 mM/L (n=20-32), BUN = 25 mg/dl (n= 7-22), creatinine = 1.2 mg/dl (n= 0.7-1.5), glucose = 60 mg/dl (n= 70-110). CBC, x-ray chest - normal. U/A - hazy, many WBC, RBC, bacteria

2. What is the differential diagnosis?  Answer

3. Patient's husband gives a history that she had a tumor removed from the head 2 years ago and has been on multiple hormone replacement medicines since then, none of which have been taken for the past 3 days because of nausea. What may be the diagnosis now?  Answer

4. How do you differentiate between primary and secondary insufficiency of this target gland?  Answer

5. What therapeutic strategy would you recommend?  Answer