Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working in the Emergency Department. Your next patient is a 35-year-old female called Mary Locksmith, complaining of general fatigue. Please take a history and perform a relevant examination.
Patient History:
Your name is Mary Locksmith – 35-year-old – unemployed.
You noticed in the past few days that you have felt much more tired than usual. You also noticed you don't feel like yourself – something is wrong, but you are unsure what is wrong. You no longer have an interest in things you used to like and have a reduced sex drive, which you find weird as you usually would go out with multiple partners. You do not think you are pregnant. Your last period was 2 weeks ago.
You have noticed you have got more freckles lately; however, you haven't been under the sun. You wish you have a holiday in Spain with the sunny weather.
You have been a bit nauseous with some tummy cramps due to recently being treated for gastroenteritis by your GP. You currently have a poor appetite. You are, however, craving salt/ salty food, so you carry a pack of salt anywhere you go. Because of your arthritis, you are on treatment for your joint pain.
Sometimes when you stand up, you feel slightly dizzy, so you usually stand there and hold on to something until the dizziness eases off.
No reduced consciousness. No fever. No SOB/ cough/ pain. No LUTS. Waterworks normal. Bowel habit normal. No diarrhoea. No recent trauma/surgery/bleeding you are aware of. No other recent acute illnesses.
Ideas, Concerns, Expectations:
You think you might have depression but do not know why – you cannot find why this is. You are concerned because you feel something is wrong, but you do not know why. You want to improve as soon as possible to feel well enough for next week's job interview.
Past Medical History:
Rheumatoid arthritis, gastroenteritis (currently), thyroidectomy (for hyperthyroidism, but you do not know the condition name)
Family History:
Type 1 diabetes
Drug History:
Prednisolone, omeprazole, levothyroxine NKDA
Social History:
You live alone in a poorer part of the neighbourhood – sharing a flat with a few other strangers.
You smoke 10 cigarettes daily for 10+ years and probably drink 2-3 cans of lager/day.
Examination Findings:
Abdominal examination / mental health assessment.
Slight mild generalised abdominal pain on palpitation.
Hyperpigmentation at lips, palmer creases and mucosa (inside the mouth).
No cushingoid features e.g. moon face, facial plethora, dorsocervical fat pad, bruising, violaceous abdominal striae, thin skin, proximal muscle weakness, or centripetal obesity.
Differentials:
Adrenal insufficiency e.g. Addison’s Disease (primary insufficiency) e.g. autoimmune (85% of cases), secondary to infection, being on steroid with sickness and vomiting / missing steroid doses
Anaemia
Depression/ Stress
Hypothyroidism
Investigations:
Conservative:
Observations: BP (hypotension/postural hypotension)
BM (to rule out hypoglycaemia / assess glucose control and diabetes)
Bloods:
FBC (infection/ anaemia/ abnormal in adrenal crisis), iron studies, vitamin D, B12 & folate, U&E ( hyponatraemia + hyperkalaemia), early morning cortisol serum/ salivary, ACTH levels (helps to differentiate primary and secondary), synacthen test, adrenal autoantibodies such as adrenal cortex antibodies & 21-hydroxylase antibodies (autoimmune causes/destruction), TFT (rule out hypothyroidism re: symptoms) and hyperthyroidism can trigger adrenal crisis), other baseline routine bloods including bone profile, LFTs, CRP), renin/aldosterone levels (to assess mineralocorticoid activity)
Short synacthen test (adrenal insufficiency)
TSH/Prolactin /FSH / LH ( assess hypothalamic-pituitary axis)
Due to the high incidence of association with autoimmune diseases - screening for thyroid and coeliac disease
DHEA/ DHEA-S which can be suppressed in primary/secondary adrenal insufficiency (adrenal produces DHEA) and may require replacement such as dehydroepiandrosterone in those with decreased libido
Overnight single-dose metyrapone test (abnormal in primary/ secondary adrenal insufficiency)
Imaging:
CT /MRI Adrenal (adrenal tumour/ haemorrhage / other structural pathology)
MRI pituitary/hypothalamus
CTTAP if suspected any metastatic malignancy
Management (Adrenal Insufficiency):