ADULT HEALTH

Case Study #1 Addison

CC:

I’ve been feeling weaker and more tired over the past 4 months, but it has taken a more severe turn for the worst since last week. I haven’t been able to enjoy any outdoor activities with my family but, for some strange reason, I’ve been getting an unusual tan”

HPI:

C.K is 48-year-old white woman who presents o her sister’s primary care provider with loss of appetite, progressive fatigue, and mild nausea for the past five days. Ck and her husband are visiting her sister in Wyoming for 2 weeks but she has not felt well enough to bicycle, hike, or climb for the past week. Her sister has insisted that she see a health care professional

PMH

Appendicitis 10 years ago

Seroconverted to PPD (+) 6 years ago: treated for 12 month with INH

Pernicious anemia X5 years

Hypercholesterolemia X1 year, controlled with diet and exercise

FH

2 sister with Hashimato thyroiditis and 1 sister with graves disease

SH

Drinks wine with dinner

Denies tobacco use with IVDU

Travels

Walks

Medication

Cyanocobalamin 200 ug IM on the 15th of every month (recently increased dose)

ROS

Swelling of the face

Big red rash that covered her torso and face, repeated fevers

Denies chills, SOB, night sweats and cough. + weight loss of 6 LBS, + salt cravings, + dizziness, one fainting spell 6 months ago, +aches and pains, -recent changes in vision, – changes in menstrual cycle, +prominent tanning of the skin although denies sun exposure.

Gen:

Tired looked

Vital signs

BP 95/75 P 83sitting rt arm

BP 80/60 P 110 standing rt arm

RR 14

T 98.0

HT 5’6

WT 124 LBs

Skin

Intact, warm and very dry

Subnormal turgor

Pigmented skin cr3eases on palms of hands and knuckles

Generalized tanned appearance

Sparse axillary hair

HEENT

Dry mucous membranes

Nect

Supple with normal thyroid and no masses

Shotty lymphadenopathy

Lungs

Clear, normal vesicular and bronchial lung sounds

Breast

Hyperpigmentation prominent along brassiere lines

Very dark areolae

Cardiac

Normal

ABD

Soft

+ BS

GU

LMP 2 weeks ago

MS

Pigmented skin creases on elbows

Pedal pulses moderately weak at +1

Lab

Na 126

Hct 33.2%

Alk Phos 115 IU/L

K 5.2

RBC 4.1

Bilirubin 1.2

Cl 97

MCV 85

Protein 8.0

HCO3 30

Plt 41

Albumin 4.7

Bun 20

WBC 6,800

Cholesterol 202

CR 1.2

Neutros 49%

Triglycerides 159

Glu 55

Lymph 36%

Fe 89

Ca 8.8

Monos 7%

TSH 3.2

Phos 2.9

Eos 7%

Free T4 16

Mg 2.9

Baso

1%

Uric acid 3.6

AST 33

ACTH 947

Hb 11.4

ALT 50

Vitamin B12

UA

Clear and yellow, SG 1.016, pH 6.45, -Blood

Imaging

Abdominal CT scan revealed moderate bilateral atrophy of the adrenal glands

Rapid ACTH stimulation test

Condition

Cortisol Assay

Aldosterone Assay

Pre-cosyntropin

2.0

3.8

30 Min post cosysntropin

1.9

3..8

Antibody testing

+ 21-hydroxylase

Negative: 17-hydroxylase

Negative: C-P450

Question:

1. What is the significance of the varying BP and HR readcing with change in position by the patient

2. What is the single greatest risk factor for addision disease in this patient?

3. What is the most likely cause of Addison disease in this patient

4. Why can tuberculosis be ruled out as a cause of Addison disease in this patient

5. Which 2 test results are most suggestive of the cause of Addison deisease in this patient

6. Would supplementation with fludrocortisone be appropriated in this patient

7. Does this patient have any signs of hypothyroidism, a disorder that is commonly associated with Addison disease

8. There are 19 clinical signs and symptoms in this case study that are consistent with Addison disease. Identify 10 and why

9. Which single test result is diagnostic for Addison disease in this patient

10. Which 3 test results support the assessment that the patient’s anemia is not the result of tiron deficiency/

11. Which 2 test result support the assessment that the patient anemia is not the result of vitamin B12 deficiency

12. Why is shotty lympadenopath consistent with a diagnosis of Addison disease?

13. What would be the plan of care for this patient

14. What are discharge instruction for this patient?