Sample Case Presentation

Agatha Stanek

July 10, 2010

•33 year- old Caucasian female presents to clinic with her younger sister complaining of vomiting, a loss of appetite, and chronic diarrhea over the last 6 days.

•Patient reports dizziness, hair loss, and abdominal pain.

•Decreased cold tolerance

•Rapid weight loss

•Patient confides in physician that she feels lost and like life is not worth living anymore; she has no strength to live.

Case presentationCase presentation

PMHPMH

•Appendicitis treated surgically 10 years ago

•Pernicious anemia x 5 years

• Formally diagnosed with anorexia nervosa at age 19 and treated successfully

•No family history of cancer

•Father died of cardiac arrest 7 years ago•Mother has Crohn disease x 22 years. Crohn disease also runs in father’s side of the family- grandfather had disease.

•Sister of patient has Graves disease

Occupational HxOccupational Hx•Patient recently moved from California to Ottawa where she is now staying with younger sister and her family.

•Upper class citizen who has a successful advertising

company- very stressful

FxFx

•Denies tobacco or alcohol use

•No children•Sister speaks to you outside and reveals that the patient is back in Ottawa after a messy divorce from her husband. She worries that the patient is depressed or she is becoming anorexic again as she has stopped eating.

MedsMeds

Cyanocobalamin, 200 µg IM; monthly. Increased dosage by physician back in the USA.

No allergies

SxSx

• no recent changes in vision, no fevers, chills, dyspnea, cough or night sweats

• changes in menstrual cycle

•Reports aches and pains

•Admits to having one fainting spell 2 weeks ago

•(+) for weight loss of 15 pounds in the last month•Patient is quite tanned, although she reports significant exposure to the sun

ROSROS

VS:BP: 95/75, P 83/min sitting T: 37 °C

BP: 80/60, P 110/min, standing HT: 5 ft- 8 ½ in

RR: 14/min WT: 121 lbs

SKIN:Intact, warm, quite dry

HEENT:•PERRLA•EOMI•Normal funduscopic exam•Dry mucous membrane

PE Results PE Results

NECKThyroid normal, no massesShotty lymphadenopathy??

LUNGSClear; normal vesicular and bronchial sounds

CARDIACRRR

ABDSoft but not tender(-) hepatosplenomegaly

GUNormal pelvic exam

MS/ EXTNormal range of motionMuscle strength throughout

NEUROAlert and orientedNormal gaitCNS II- XII intact

•Anorexia nervosa/ Severe nutritional deficiencies•Depression•Colon disease…•Infection•Pituitary failure/ hypothalamic tumour

Differential DiagnosisDifferential Diagnosis

Laboratory Blood Test Results

UA: •Clear and yellow•SG 1.1016•pH 6.45•(-) blood

Antibody Testing:• (+) 21- hydroxylase•(-) 17-hydroxylase•(-) C-P450

Peripheral Blood Smear:Normal, normocytic erythrocytes

Additional TestsAdditional Tests

Why are these tests results significant???

Autoimmune Addison disease (AD)-Why autoimmune?

-Why is shotty lymphadenopathy consistent with this diagnosis in this particular patient?

-Why was the patient anemic?

-What other imaging test can confirm this test result? -CT scan: which revealed moderate bilateral atrophy of the adrenal glands.-MRI

Diagnosis Diagnosis

No cure for AD•Glucocorticoid and possibly mineralocorticoid replacement therapy

•Hydrocortisone- daily oral dose of 15-25 mg in 2 doses; 2/3 in the am and 1/3 in the pm.•Proper dose results in normal differential WBC count.

• Fludrocortisone- daily 0.05-0.3 mg orally

•No restrictions on physical activity required

•Diet: include at least 150 meq of Na daily; more if excessive sweating/ diarrhea occur

Treatment Treatment

•Proper control results in a good long-term prognosis and normal life expectancy

•Complications:•Addisonian crisis•Cushing syndrome•Neurologic disease•Life-threatening systemic infection?

Serious Complications and Prognosis

Suggest colonoscopy to rule out…

Recommend outpatient therapy- counselling. Referral to nearby psychologist.

Further RecommendationsFurther Recommendations