CASE SCENARIO 2: ADDISON’S DISEASE

HEALTH HISTORY

Three months prior to admission, Sally manifested muscle weakness, easy fatigability,
increasing darkening of the skin, nausea with occasional vomiting. She mentioned a
progressive weight loss from 68 kgs to 50 kgs. She was referred to a gastroenterologist for
her nausea and occasional vomiting and was ordered to undergo upper GI endoscopy but
she failed to because of financial constraints.

There were no headaches, blurred vision, and neither loss of consciousness nor change in
her bowel habit. The medical history and systemic review revealed no abnormality and were
not significant as to the likely cause of her disease state.

SOCIAL HISTORY

Patient Sally T. Lopez, 49 years old, married with three children and residing in the coastline
area of Himalayan City. She is an elementary teacher in Cabanbanan Elementary School,
Himamaylan City. Her husband is a tricycle driver. She does not smoke cigarettes, she
mentioned that she tried drinking alcohol when she was in high school due to peer pressure.
She’s not also engaging in any form of drug related substances. She has a strong faith in God
and very positive in life. She was unsure of any relevant family history.

HISTORY OF PRESENT ILLNESS

24 hours prior to admission, Sally had a persistent vomiting 5 to 15 times a day and severe
weight loss. Her present weight is 50 kgs where she lost a total of 18kgs in 3 months. She
was rushed in the emergency room due to severe body weakness and dehydration.

On examination she was very thin and hypotensive. Physical examination revealed asthenic
with generalized hyperpigmentation especially on the face, oral mucosa, palmar creases and
knuckles. Loss of skin turgor and dry oral mucous membranes was also evident.Her vital
signs were: pulse is 106bpm, regular and strong, blood pressure of 80/60mmhg,
temperature is 36 and RR is 24 cpm.

No features of malnutrition/ vitamin deficiency. There was no blurred vision, headache nor
changes in her bowel habit. All other systems were essentially normal.

1. Patient’s Information
Name : SALLY T. LOPEZ
Address : BRGY TABIGUE, HIMAMAYLAN CITY
Age : 64 YO
Sex : FEMALE
Civil Status : MARRIED
Date of birth : JANUARY 24, 1959
Educational Attainment : COLLEGE GRADTUATE
Occupation : ELEMENTARY TEACHER
Religion : ROMAN CATHOLIC
2. Other Information
No. of dependents :3
Date of admission :February 7, 2023, 5:30am
 Chief complaints :persistent vomiting and weight loss
Weight : 50 kgs
Height : 152 cm
Admitting diagnosis :Addison’s Disease
Allergies :NONE
Attending Physician : DR. VALERIE TORRES- GAMBOA

1. Initial Assessment and findings:

1. Weight: 50kgs
2. dry skin and oral mucous membranes
3. poor skin turgor
4. dark pigmentation over the face
5. (+) generalized body malaise

2. Doctor’s Order
DATE DOCTOR’S ORDER
February 7, 2023 Pls admit under the service of Internal Medicine (SCU)
5:30am TPR q4h
MIO q shift

BP: 80/60
Diet: NPO temporarily
HR: 106bpm Labs: CBC,Platelet
RR: 24cpm RBS, Na, K, Cl
T: 36.0 C
Urinalysis
O2 sat: 98%
ESR, CRP
Wt: 50kgs
TSH, T4 and T3
ACTH level test, cortisol level test

IVF: PNSS 1L fast drip 200cc then regulate at 120cc/hr

IVF to follow: PNSS 1L x 120 cc/hr x 2 bottles
Medications:
Solu-Cortef 100mg IVTT q4h
Reglan 10mg IVTT q8h PRN for vomiting
Vitcee 500mg 1 tab BId p.o.
S/O:
> Replace GI loses vol/vol
> Place patient in recumbent position with legs elevated
> Monitor for signs of Addisonian crisis
>Weigh daily
>Fall precaution
> Refer accordingly
Dr. Gamboa
Lic. No. 063092
February 7, 2023 Start Axetil 750mg IVTT q8h ANST

10:00 am Give 50ml D50 + 10 U regular insulin now to run for 15-30 mins

Levothyroxine 50 mcg po ODac

Fludrocortisone 50mcg po ODpc

3. Laboratory & Diagnostic Findings

COMPLETE BLOOD COUNT

Test Requested Result Normal Values
Hemoglobin 140 120-170 g/L
Hematocrit 0.40 0.40-0.54
RBC Count 4.60 4.00-5.50x10^12/L
WBC Count 13.90 5.00-10.00x10^9/L
Differential Count
Neutrophil 0.60 0.50-0.70
Lymphocyte 0.31 0.20-0.40
Eosinophyl 0.04 0.00-0.05
Monocytes 0.05 0.00-0.09
Basophil 0.00 0.00-0.01
Platelet 280 150.00-400.00x10^9/L

URINALYSIS
Physical Chemical
Color Dark Straw Albumin Negative
Reaction pH 6.0 Sugar Negative
Transparency Hazy Ketones Negative
Specific Gravity 1.020 Bilirubin Negative
Microscopic Cells Leukocytes Trace
Pus Cells 0-2/HPF Blood Negative
RBC 0-3/HPF Nitrite Negative
Yeast Cells - Urobilinogen Negative
Bacteria -
Epithelial Cells - Microscopic Crystals
Casts - Amorphous Urates Few/lpf
 Clinical Chemistry
S.I. Unit Conventional
Test
Result Normal Value Result Normal Value
RBS 110 80-130 md/dL
Sodium 129.00 135-148 mmol/L
Potassium 5.9 3.5-5.0 mmol/L
Chloride 104.00 98-107mmol/L
ESR 55 0-29 mm/hr
CRP 16 <10 mg/L

THYROID PANELS
EXAM NAME RESULT NORMAL VALUES
TSH 30 mIU/L 0.5-5.0 mIU/L
T3 130 ng/dL 100-200 ng/dL
T4 9 mg/dL 5 – 12 mg/dL

EXAM NAME RESULT NORMAL VALUES

Cortisol Level 5mcg/dL 10-20 mcg/dL
ACTH level 7 pg/mL 10-60 pg/mL