Cruz, Janel

Case study: Addison's Disease

HPI
Mrs. Smith is a 40 year old tech startup executive. She initially presented to the clinic with
unexplained fatigue even when she had a full 8 hours of sleep. Which she notes was enough
before. There was no change to her daily activities to explain the sudden fatigue. Her main
concern is her unexplained weight loss of around 5 kg in one month. The patient remarked that
her cravings had also changed. She is a self professed sweet tooth who didn't care for salty
foods. Though now, she has stated that she craves salty snacks like salted nuts, chips
especially the vinegar kind as well as hard cheese. She presented with hyperpigmentation on
her face, neck, arms and leg. No significant prior medical history, currently on no medication.
She has been told by MD to perform stat labs.

Assessment
Patient was seen in the clinic. Vital signs are 96/64, HR 84, RR 18, T 37 C. Patient reported that
she still feels tired. She is sitting slouched on the examination table. Skin is pale and the
patient's weight loss is still a concern. Her lab results have come back with an elevated ACTH,
hyponatremia and hyperkalemia, serum cortisols were low, CBC is within normal range and
TSH is within normal range.

Primary DX
Primary addison's disease is a rare endocrine disorder. The hallmark feature is the insufficient
production of hormones by the adrenal gland. The others include extreme fatigue, unexpected
weight loss and loss of appetite, bronze skin, hypotension, salt cravings, low blood sugar,
irritability and body hair loss, and muscle weakness. The most common cause for addisons is
an autoimmune disease that targets the adrenal glands. The other possible causes are
infections like tuberculosis, HIV and fungal infections that cause damage to the adrenal glands
when they become inflamed. Adrenal gland disorders may also cause addison's disease and
cancer. If Addison's disease is left untreated then this will lead to an adrenal crisis, It is fatal if
not treated.

Rationale: Mrs Smith presents with symptoms that align with Addison's disease. Such as
hyperpigmentation, persistent fatigue, unexplained weight loss, cravings for salty foods and
muscle weakness. Her lab test also came back and they indicate low cortisol levels, elevated
ACTH, hyponatremia and hyperkalemia. The combination of these symptoms and lab test
indicate for addison's disease.

Diagnostics
Test Result Reference

Cortisol ↓ 3.8 mcg/dL 6.2 - 19.4 mcg/dL

ACTH ↑ 65 pg/mL 9 - 52 pg/mL

Sodium ↓ 129 mEq/L 135 - 145 mEq/L

Potassium ↑ 5.2 mEq/L 3.5 - 5.0 mEq/L

CBC within range

TSH within range

Plan
Diagnostics

21-Hydroxylase Antibodies to test for addison's antibodies

Repeat electrolyte panel, looking specifically for the values of sodium and potassium. The
return to reference values will indicate efficacy of medication regimen.

Repeat ACTH and Cortisol levels to indicate the effectiveness of medication regimen and to fine
tune the dosage and frequency of administration.

Medication regimen
Rx: Hydrocortisone Tablet

20mg, in the morning and 10 mg in the afternoon, PO

Dispense: 30
Rationale: To replace cortisol which will address fatigue and weight loss
Rx: Fludrocortisone

0.1mg, daily PO
Dispense: 30
Rationale: to supplement mineralocorticoid which will correct the hyponatremia and
hyperkalemia
- Needs an increased salt intake
Sodium Chloride tab

1g, with meals PO

Rx: Dehydroepiandrosterone (DHEA)

25mg daily, PO
Rationale: androgen replacement

Education
Medication
- Educate her on the importance of adhering to her medication regimen. Taking the proper
dose at the right time is crucial for hormone regulation.
- These medications supplement the hormones in her body. Therefore these medications
will be taken for life. Follow the medication instructions as prescribed by the MD
- The two steroids hydrocortisone and fludrocortisone will decrease immune function
causing an increased chance for infections.
- Hydrocortisone is timed like that to mimic the body's hormone rhythm. Stress the
importance of taking the right dose at the right time. Common side effects include:
dizziness, headaches, swollen ankles and feeling weak.
- Common side effects for fludrocortisone include: upset stomach, vomiting , headache,
dizziness, acne
- DHEA common side effect include: acne, stomach upset, rapid heartbeat
- Advice for her to have a system in place when she travels so she won't miss a dose.
- Immediately call emergency services for signs to allergy symptoms such as shortness of
breath, wheezing, swelling of the face, lips, and throat, rash or hives.
Folloups
- A follow up appointment will be needed to go over the lab test results and for any
adjustment for her medications
- There will be regular blood test to check ACT, cortisol and electrolytes. The medication
dosage will be based on blood test results. More blood test may be required such as a
CBC when showing signs of infection
 - As the medications suppress immune system have the patient report to MD for any signs
and symptoms of infection such as fever, chills, abdominal pain, cough, headache and
nausea and vomiting
Stress management
- Manage stress to not spike cortisol levels, this can be done by incorporating mindfulness
and meditation.
- Exercise has been shown to help manage stress. Do it as tolerated and as allowed by
the MD
Hyperpigmentation
- The darkening of the skin will primarily affect skin that is exposed to the sun.
Recommend sun protection in the form of sunscreen and spf rated clothing. Advise to
reapply sunscreen as needed.
Diet
- A balanced diet is recommended. Follow the dieticians recommendations and plans.
- An increase in salt intake is recommended. For people without addison's 9g of salt is
recommended. For those with addison's 30-60g is recommended. This is due to the
excessive loss of salt through the urine. Replacement through diet is needed
Adrenal crisis
- Educate the patient and family on these signs and symptoms: severe weakness, acute
abdominal pain, vomiting and altered mental status, dizziness, hypotension. This is a
medical emergency and the patient needs to be brought to the emergency room
- This is can be caused by adrenal insufficiency, dehydration, infection, stressReferral

Follow up

SOAP
HPI - patient presented to the clinic for a follow up from the last visit dated 3 days ago. Md
ordered STAT labs for suspected Addison disease. The patient with the only one in the the only
in the system is not in the

Patient
Subjective -
Objective
Assess,emt
Plan
Reference

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297573/

https://emedicine.medscape.com/article/116467-clinical?form=fpf

https://www.hopkinsmedicine.org/health/conditions-and-diseases/underactive-adrenal-glands--
addisons-disease#:~:text=The%20primary%20kind%20is%20known,enough%20of%20the
%20hormone%20ACTH.

https://www.ncbi.nlm.nih.gov/books/NBK441994/

https://pubmed.ncbi.nlm.nih.gov/35411072/

https://www.mayoclinic.org/diseases-conditions/addisons-disease/symptoms-causes/syc-
20350293

https://medlineplus.gov/lab-tests/adrenocorticotropic-hormone-acth/

https://www.ncbi.nlm.nih.gov/books/NBK441832/

https://www.nhs.uk/conditions/addisons-disease/treatment/#:~:text=Medicine%20for
%20Addison's%20disease&text=A%20medicine%20called%20hydrocortisone%20is,with%20a
%20medicine%20called%20fludrocortisone.

http://oregon-ent.com/patient-education/hw-view.php?DOCHWID=hw65865#:~:text=Get
%20enough%20salt%20in%20your,Monitor%20your%20blood%20pressure.

https://www.picmonic.com/pathways/nursing/courses/standard/medical-surgical-nursing-
pathophysiology-296/adrenal-disorders-1416/addison-s-disease-intervention_1744

https://www.nhs.uk/medicines/hydrocortisone-tablets/#:~:text=2.-,Key%20facts,more%20likely
%20to%20get%20infections.

https://medlineplus.gov/druginfo/meds/a682549.html

https://www.mims.com/philippines/drug/info/hydrocortisone?mtype=generic