A CASE OF ADDISON’S DISEASES AND MANAGEMENT.pptx

A clinical case presentation of addison's disease and its management

1. A CASE OF ADDISON’S DISEASE BY ENDOCRINOLOGY UNIT TEAM C

2. BIODATA Name: C. H. Age: 61 Years Sex: female Occupation: civil servant Marital status: Married Address: Idumuje unor Religion: Christian Origin: Idumuje unor Informant: Patient and son

3. PRESENTING COMPLAINTS Recurrent bouts of profuse watery diarrhea x 3/52 Generalised weakness x 3/52 Recurrent hypoglycaemia of 7 years duration

4. Patient was in her usual state of health until about 3/52 prior to presentation when she developed diarrhea. Stools were watery, non-mucoid, no haematochezia , no melaena, no abdominal pain. She had between 5-10 bowel movements/day. There was associated vomiting of recently ingested meals. It was non projectile, not copious, and not bloody

5. Diarrhea was accompanied by profound generalised weakness with associated malaise and anorexia but no weight loss No history of previous stroke, recurrent headache, limb weakness, transient visual loss nor inability to move the limbs No history of use of psychoactive substance No history of easy bruising or bleeding from any orifice

6. For the above complaints, she presented to a private hospital 3/7 prior to presentation to this facility. There, the RBS was said to be 26mg/dl and correction was done with dextrose containing fluids There is history of several similar scenarios in the past (diarrhea, vomiting, generalised weakness and hypoglycaemia ). Random blood glucose has been known to drop to between 20-30mg/dl on many occasions. She had sort care at numerous hospitals, but the condition persisted.

7. She is not a known diabetic and has never been on anti-diabetic medication. She had cholescystectomy in 2016. She is not a known hypertensive, epileptic nor asthmatic She is the 10th of 12 children There is a Family history of hypertension and diabetes mellitus She is married in a monogamous family setting with 4 children Does not consume tobacco nor alcohol

8. SUMMARY Mrs. C.H., a 61 years old female who presented with complaints of recurrent bouts of profuse watery diarrhea x 3/52, generalised weakness x 3/52, and recurrent hypoglycaemia of 7 years duration, with associated vomiting, and anorexia but no weight loss. There is history of several similar scenarios in the past. She is not a known diabetic and has never been on any anti-diabetic medications

9. O/E: A middle aged woman, in no obvious distress, pale, afebrile (36.4C), anicteric, acyanosed , dehydrated with reduced skin tugor , hyperpigmentation of palmar crease,elbow and pressure area, nil digital clubbing, no pedal oedema.

10. CVS: PR: 88bpm, normal volume, regular R-R Synchronicity, other pulses palpable Thickened Arterial Wall, Locomotor Brachialis BP: 100/70mmHg JVP not raised Apex was at the 6th LICS HS: S1,S2

11. CHEST: RR: 18cpm Trachea was central Equal chest expansion bilaterally Tactile fremitus normal in all lung zones Percussion note was resonant in all lung zones with preservation of areas of cardiac and hepatic dullness Vesicular breath sounds

12. CNS: Conscious and alert, oriented in time, place and person Neck was supple, nil meningeal signs Pupils were 3mm reactive to light Cranial nerves 3, 4 and 6 intact Muscle bulk was normal in all muscle groups Normotonia globally Gross power of 5/5 in all limbs Gait was not assessed

13. ABDOMEN: Full, moved with respiration Old midline surgical scar No areas of tenderness Liver, and spleen not palpable, kidneys not ballotable BS: present and normoactive Nil Ascites RBS at review was 55mg/dl

14. AVAILABLE INVESTIGATION RESULT S/E/U/Cr: Severe hyponatremia, mild hypokalemia UREA.......................1.4............................. mmoL /L (1.66 - 8.0 mmoL / CREATININE................82.......................... umoL /L (72 - 127 umoL /L) SODIUM....................107............................ mmoL /L (130 - 146 mmoL /L) POTASSIUM...............3.0.......................... mmoL /L (3.3 - 5.0 mmoL /L) CHLORIDE.....................75....................... mmoL /L (90 - 108 mmoL /L) BICARBONATE................25..................... mmoL /L (20 - 32 mmoL /L)

15. ASSESMENT: ?Neuroendocrine tumor (Insulinoma, VIPoma) PLAN: Contrast Abdominal CT-scan 30mls of 50% D/W then maintain on IVF 10% D/W 500mls 12hourly IVF Normal saline 500mls 6hrly on alternate arm with 10mmol of IV KCl added to alternate infusions 4hrly RBS checks Repeat E/U/CR IV Metoclopramide 10mg 12hrly x 48 hours Invite Endocrinology to review and co-manage Retrieve outstanding investigation results

16. DAY 2 - CWR ENDOCRINOLOGY A 61yr old civil servant who presented a day ago with recurrent vomiting, diarrhea and recurrent hypoglycemia of 6years. Index presentation started 3 weeks ago. Patient was admitted in our facility in 2019 for same complaints, stayed for 24days, was discharged to do some investigations outside like CT scan and follow up in clinic. Patient did not follow up with investigations nor clinic visit due to financial constraints.

17. Other history as previously documented Patient is not a known diabetic nor hypertensive RBS at the referring peripheral hospital = 26mg/dl Admitting RBS: 55mg/dl RBS on review: 91MG/DL Patient currently on 10% D/W

18. O/E: A middle aged woman, in no obvious distress, pale, afebrile (36.4C), anicteric, acyanosed , dehydrated with reduced skin tugor , hyperpigmentation of palmar crease and pressure areas, nil digital clubbing, no pedal oedema CNS: Conscious and alert oriented in time place and person CHEST: RR: 18cpm Vesicular breath sounds

19. CVS: PR: 88bpm, normal volume, regular BP: 110/70mmHg HS: S1,S2 ABDOMEN: Full, moves with respiration Nil palpable organ Ascites nil BS: present and normoactive

20. AVAILABLE INVESTIGATION RESULT PCV..............................28................................... (MALE: 40-54%, FEMALE: 36-46%) HB................................................................... (11-17g/dl) TWBC..........................3200................................... (4-10,000 mm3) DIFFERENTIAL WBC NEUTROPHILS.............30......................... (40-70%) LYMPHOCYTES.............59........................ (20-50%) EOSINIPHIL...................03......................... (1-6%) MONOCYTES.................08........................ (1-10%) BASOPHILS....................00........................ (=<1%) MP:............................................SEEN/NOT SEEN RED CELL MORPHOLOGY: MICROCYTOSIS +, HYPOCHROMASIA +, PLATELET COUNT: 135,000cells/mm3

21. ASSESEMENT: Recurrent hypoglycemia ? Cause ? Neuroendocrine tumor (Insulinoma, VIPoma) Anemia

22. PLAN: Transfer patient to female medical ward under Dr. Okocha To do Abdominal CT scan, C- Peptide, and Insulin levels, Peripheral blood film Continue IVF 10% D/W 6hrly 2hrly RBS and if <100mg/dl, correct with 30mls of 50% D/W. If glucose >200mg/dl, stop dextrose infusion till next check Correct hyponatremia with 0.9% on contralateral hand as previously documented Tabs Fesolate 200mg TDS Tabs Vitamin- C 200mg TDS Retrieve all outstanding investigations Continue other on-going management

23. DAY 3 – RWR GASTROENTEROLOGY As at the time of review, no vomiting since last review. However, patient was restless the previous night and increasing drowsiness this morning. No more diarrhea Renal scan done was normal, yet to do abdominopelvic CT scan. O/E: Pale, anicteric, afebrile, acyanosed , not dehydrated, no digital clubbing, nil pedal oedema. CVS: PR: 68bpm BP: 100/70mmHg

24. ABD: Full, MWR, No areas of tenderness Old midline surgical scar Organs not palpable No ascites CHEST: RR: 20cpm BS: Vesicular CNS: Conscious, lethargic Well oriented No focal neurologic deficit

25. ASSESEMENT: ? Neuroendocrine tumor (Insulinoma, VIPoma) PLAN: RBS 4hrly check Encourage to take salt water solution three times daily Encourage to take potassium containing foods Encourage to do Contrast Abdominal CT-scan IVF 10% D/W 500mls 12hourly IVF Normal saline 500mls 6hrly on alternate arm with 10mmol of IV KCl added to alternate infusions If RBS is <70mg/dl correct hypoglycemia If SpO2 is <92% commence intranasal oxygen. Repeat E/U/CR IV Metoclopramide 10mg 12hrly x 48 hours

26. DAY 5 – CWR ENDOCRINOLOGY Patient seen No more passing loose stool and having diarrhea RBS in the morning: 84mg/dl RBS on review: 121mg/dl O/E: A middle aged woman, in respiratory distress (INO2), reduced skin turgor, nil digital clubbing, no pedal oedema

27. CVS PR - 60bpm BP - 100/60mmHg NS: Conscious, lethargic GCS - 9/15 E-2, V-3, M-M4

28. UREA.........................1.6........................... mmoL /L (1.66 - 8.0 mmoL /L) CREATININE...............74........................... umoL /L (72 - 127 umoL /L) SODIUM.....................101........................... mmoL /L (130 - 146 mmoL /L) POTASSIUM..................2.1....................... mmoL /L (3.3 - 5.0 mmoL /L) CHLORIDE.....................73....................... mmoL /L (90 - 108 mmoL /L) BICARBONATE..............29....................... mmoL /L (20 - 32 mmoL /L)

29. ASSESEMENT: ? Addisonian crisis and Dyselectrolytemia PLAN: Invite CTU to pass central line Do CXR, Urgent serum cortisol level, daily S/E/U/Cr IV Hydrocortisone 200mg stat then 100mg 6hrly x 48hrs 4hrly blood glucose monitoring; if RBS < 100 give 30mls of 50% D/W in double dilution Discontinue 10% D/W Alternate 500mls of 3% hypertonic saline with 250mls of normal saline with 20mmol of KCL x 6hrly Close vital signs and fluid monitoring

30. DAY 6 – RWR GASTRO Attention drawn to this patient this morning around 10:30am on account of breathlessness. There is a paucity of peripheral venous access and a consult to CTU had already been given the previous day but materials for central venous cannulation are yet to be procured. BP: 90/40 mmHg PR: 48 bpm SpO2- 85% ASSESEMENT: ? Addisonian crisis (in shock)

31. PLAN: Secure an IV access (done) IV Dopamine 200mcg in 250mls of normal saline @ 8dpm(done) Monitor vitals every 15mins Continue other care 30mins later BP - 90/60mmHg, PR - 78bpm

32. CWR - GASTROENTEROLOGY Vomiting has subsided, however said to have had an episode of watery stool last night. Said to have become breathless this morning with SpO2 of 85%. She was immediately started on INO2. SpO2 has improved to 97-98% on INO2. Serum Na and k at admission were 101 & 3mmol/L respectively. A repeat was done after commencement of 0.9% saline + 20mmol of KCL showed Na - 101 & k- 2.1 mmol/L respectively.

33. Fasting Lipid Profile showed hyperlipidemia Report of abdominal CT scan still awaited O/E: A middle aged woman in respiratory distress on INO2 at 5l/min, mildly pale, afebrile, anicteric, acyanosed with minimal ankle edema . CNS: Altered consciousness GCS-9/15 ( E-3 V-2 M-4) No demonstrable meningeal sign

34. CVS: BP: 90/60 mmHg PR: 72 bpm HS: S1 S2 CHEST: RR: 16 cpm BS: vesicular with transmitted sounds anteriorly

35. PROBLEMS Hyponatriemia Hypokalemia Recurrent hypoglycemia Hypotension Impaired consciousness ASSESEMENT: ? Adrenal Hypofunction R/O Neuroendocrine Tumor

36. PLAN: Send abdominal CT scan for reporting Invite chemical pathology for review o/a of severe hyponatremia & hypokalemia IVF 0.9% saline 500mls 6hrly + 20mmol of KCl in alternate infusion Continue RBS monitoring 4hrly Continue IV Hydrocortisone 100mg 8hrly KIV commencement of hypertonic saline after review by chemical pathology Satchet floranorm 1 bd Tabs Zinc 20mg bd Tabs Atorvastatin 20mg nocte Continue other care Reminder to CTU for central line

37. RWR - ENDOCRINOLOGY Patient seen RBS in the morning: 150mg/dl RBS on review: 189mg/dl Consult has been sent to CTU team for central line, materials have been bought, but the central line was still yet to be passed as at the time of review

38. O/E: An middle aged woman, in respiratory distress (INO2), reduced skin turgor, nil digital clubbing, no pedal oedema CVS: PR - 72bpm BP - 90/60mmHg NS: Conscious, lethargic GCS - 9/15 (E-2, V-3, M-M4)

39. PLAN: Continue Dopamine infusion Continue IV Hydrocortisone Continue blood glucose monitoring Encourage to do serum cortisol level Continue other care

40. DAY 7 – RWR GASTROENTEROLOGY No vomiting or diarrhea in the last 24hours Central line has been passed Couldn’t get KCL yesterday as it wasn’t procured RBS: 144mg/dl this morning No fresh complaint O/E: A middle aged woman in no obvious distress, mildly pale, afebrile, anicteric, acyanosed with minimal ankle edema

41. CVS: PR - 72bpm BP - 90/60mmHg NS: Conscious, lethargic GCS - 9/15 (E-2, V-3, M-M4)

42. ASSEMENT: ?Adrenal hypofunction R/O Neuroendocrine tumor PLAN: Continue IV fluid Encourage to procure hypertonic saline Consult to chemical pathologist Continue 20mmol/l of KCL in 500mls of normal saline 6hrly in alternate infusion Repeat S/E/U/Cr Continue other management

43. DAY 7 – SRWR GASTROENTEROLOGY No vomiting or diarrhea for 2/7 RBS - 157 mg/dl this morning No fresh complaint O/E: A middle aged woman in no obvious distress, mildly pale, afebrile, anicteric, acyanosed with minimal ankle edema

44. CNS: Conscious no demonstrable meningeal deficit CVS: BP - 110/60 mmHg PR -75 bpm HS - S1 S2

45. UREA...................2.9................................. mmoL /L (1.66 - 8.0 mmoL /L) CREATININE...............98........................... umoL /L (72 - 127 umoL /L) SODIUM.....................119........................... mmoL /L (130 - 146 mmoL /L) POTASSIUM...............3.7.......................... mmoL /L (3.3 - 5.0 mmoL /L) CHLORIDE...................85......................... mmoL /L (90 - 108 mmoL /L) BICARBONATE.............28........................ mmoL /L (20 - 32 mmoL /L)

46. ASSESEMENT: ?Adrenal hypofunction R/O Neuroendocrine Tumor PLAN: Continue IVF Normal saline Procure hypertonic saline (100mls IVF 3% Hypertonic saline + 100mls IVF Normal saline over 4hrs stat) Discontinue 20mmol of KCL in 500mls of normal saline 6hrly in alternate infusion Repeat S/E/U/Cr tomorrow

47. DAY 11 – SRWR GASTROENTEROLOGY No vomiting or diarrhea for the past 7 days RBS - 101mg/dl this morning Complains of inability to pass stool x 4/7 Has been taking fruits daily Patient has shown significant improvement

48. O/E: A middle aged woman in no obvious distress, mildly pale, afebrile, anicteric, acyanosed with minimal ankle edema CNS: Conscious no demonstrable meningeal deficit CVS: BP - 110/60 mmHg PR - 64 bpm HS - S1 S2

49. UREA..........................3.1.......................... mmoL /L (1.66 - 8.0 mmoL /L) CREATININE..............97............................ umoL /L (72 - 127 umoL /L) SODIUM...................127............................. mmoL /L (130 - 146 mmoL /L) POTASSIUM............3.4............................. mmoL /L (3.3 - 5.0 mmoL /L) CHLORIDE................90............................ mmoL /L (90 - 108 mmoL /L) BICARBONATE.........26............................ mmoL /L (20 - 32 mmoL /L)

50. ASSESEMENT: ? Adrenal Hypofunction R/O Neuroendocrine Tumor with Dyselectrolytemia (Hyponatremia) PLAN Continue salt and water intake Bladder training then remove catheter Repeat S/E/U/Cr Suspension lactulose 10mls TDS to achieve 2-3 loose stools per day Continue other care

51. CWR - ENDOCRINOLOGY RBS - 101mg/dl this morning Complains of inability to pass stool x 4/7 O/E: A middle aged woman in no obvious distress, mildly pale, afebrile, anicteric, acyanosed with minimal ankle edema

52. CNS: Conscious no demonstrable meningeal deficit CVS: BP - 100/60 mmHg PR - 60 bpm HS - S1 S2

53. ASSESEMENT: ? Resolving Addisonian crisis PLAN: D/C Urethral catheter Change IV Hydrocortisone to Prednisolone 10mg TDS Counsel on ingestion of fruits and vegetables Continue other care

54. DAY 12 – CWR GASTROENTEROLOGY Diarrhea & vomiting has subsided CT scan showed a smooth solitary small thin-walled subcapsular liver nodule that does not enhance. Hepatitis viral screening were all negative.

55. O/E: General condition is stable PR - 62bpm BP -110/70 mmHg ASSESEMENT: Subcapsular liver nodule ? Cause PLAN: Discharge from Gastro in-patient care Do HBV 5 panel test, PCV, PT-INR, Platelet count Work up for Liver needle aspiration under Ultrasound guidance Tabs Silymarin 70mg daily Tabs Vitamin B-complex II bd See Gastro clinic in 2/52

56. RWR - ENDOCRINOLOGY FBS = 68mg/dl Patient started receiving Tabs Prednisolone yesterday evening O/E: A middle aged woman, in no obvious distress, not dehydrated, nil digital clubbing, no pedal oedema PR - 60bpm BP - 130/80mmHg NS: Conscious

57. SERUM CALCIUM = 1.80mmoL/L REFERENCE RANGE............................2.25 - 2.75 mmoL /L SERUM CORTISOL 63.4ug/dL ..............................(5-22)

58. UREA..........................5.0.......................... mmoL /L (1.66 - 8.0 mmoL /L) CREATININE..............102........................ umoL /L (72 - 127 umoL /L) SODIUM...................130..................... mmoL /L (130 - 146 mmoL /L) POTASSIUM............3.5.......................... mmoL /L (3.3 - 5.0 mmoL /L) CHLORIDE................92......................... mmoL /L (90 - 108 mmoL /L) BICARBONATE.........24............................ mmoL /L (20 - 32 mmoL /L)

59. ASSESEMENT: ? Addisonian crisis PLAN: Retrieve FLP Discontinue IVF N/Saline Discontinue SC Enoxaparin Tabs Clopidogrel 75mg daily Encourage to take fluids liberally orally Continue salt-water intake Continue blood glucose monitoring: < 60mg/dl, give 30mls of 50% D/W Continue other care

60. DAY 13 – RWR ENDOCRINOLOGY FBS = 96mg/dl Nil fresh complain today O/E: A middle aged woman, in no obvious distress, not dehydrated, nil digital clubbing, no pedal oedema PR – 54 bpm BP - 130/90 mmHg N/S: Concious

61. FLP REFERENCE VALUE TOTAL CHOLESTEROL..............7.2............ mmoL /L (3.3 - 5.3 mmoL /L) TRIGLYCERIDE....................2.4................... mmoL /L (0.1 - 1.7 mmoL /L) HDL - CHOLESTEROL.............0.9................ mmoL /L (0.9 - 2.1 mmoL /L) LDL - CHOLESTEROL................5.2.............. mmoL /L (2.0 - 3.6 mmoL /L)

62. ASSESEMENT: Addisonian crisis PLAN: Discharge home today on - Tabs Hydrocortisone 20mg morning, 10mg evening - Tabs Clopidogrel 75mg daily - Tabs Artovastatin 20mg nocte - Tabs Fesolate 200 tds - Tabs Vitamin C 200mg tds Encourage to take fluids liberally orally Continue salt-water intake Continue daily blood glucose monitoring and charting See Endo clinic in 1/52

63. ENDOCRINOLOGY CLINIC Patient seen Was discharged last week and managed as a case of Addison's disease Currently on tabs Hydrocortisone FBS: 74mg/dl O/E: GCS BP - 140/70mmHg

64. PLAN: Tabs Hydrocortisone 20mg morning, 10mg evening Tabs Clopidogrel 75mg daily Tabs Artovastatin 20mg nocte Tabs Fesolate 200 tds Tabs Vitamin C 200mg tds See Endo clinic in 2/52

65. THANK YOU