Adult Health Case Study Paper
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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?
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