His worried colleagues claim that he has been lethargic for a few weeks, with episodes of abdominal pain and seems to have lost weight. They initially blamed it on him losing money at RWS.
BP 100/60, Temp 37.6
Groaning away
abdo : diffusely tender
UC9 : negative for WBC, blood, glucose or protein
Na 128, K 6.5, Urea 14, Bicarb 12.8 (all in mmol/l)
What is your diagnosis?
Answer : Addisonian crisis
- acute and life-threatening condition due to adrenal (cortisol and aldosterone) deficiency.
- most common cause : adrenal suppression due to long-term corticosteroid use with subsequent abrupt withdrawal or sudden exposure to increased stress (e.g. illness, injury, surgery etc).
- other causes : autoimmune adrenalitis (in developed countries), infections e.g. TB (developing countries), metastasis, heparin therapy
- Weakness, nausea, vomiting
- abdominal pain
- weight loss, loss of appetite
- increased pigmentation of skin and mucous membrane
- Inx : hyponatremia, hyperkalemia, metabolic acidosis, hypoglycemia, pre-renal azotemia
- Definitive tests such as the short and long Synacthen tests are usually not done at the level of the ED
- High index of suspicion
- fluid resuscitation (dextrose saline preferable)
- IV Hydrocortisone 100 mg bolus (Hydrocort messes up the synacthen test so may consider using IV Dexamethasone 4 mg IV instead)
- Search for precipitating cause (e.g. sepsis, trauma, acute coronary syndrome etc)
- Admit to HD/ ICU under Endocrinologist for close monitoring and management
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