Mr Paul Pitations is a 65 year old man who has presented to his GP feeling tired. He says he has lost 1 stone in weight over the past 2 months, unintententionally, but cannot think why. He does not have a cough, though has had intermittent diarrhoea. He has felt more irritable lately, and is very concerned that he is becoming more muddled. His dad had dementia quite young, therefore this is playing on his mind a lot.
Paul is mildly tachycardic at 104bpm and his respiratory rate is 14. His temperature is 37.6 degrees celcius. His blood pressure lying down is 118/67, however this drops to 88/54 on standing. He recently had a knee operation, and he shows you the scar. You notice that the scar has an area of hyperpigmentation. The inside of his mouth also is hyperpigmented.
You send off a list of routine bloods, which comes back:
Na: 121
K: 6.0
Urea: 5.1
Creatinine: 65
Thyroid function tests: normal
Over to you - what would you like?
8am cortisol level: 130nmol/L
Cortisol levels pre ACTH: 120nmol/L
Cortisol levels post ACTH: 125nmol/L
CT head report: Age-related white matter changes, no evidence of acute bleed or infarct
MRI report: no evidence pituitary masses
Now select your winner!
You picked:
Correct answer:Addison's disease
Here we have a patient who has presented with some symptoms which appear initially concerning: weight loss and change in bowel habit. He also has confusion. This could be a presentation of malignancy, or of an electrolyte disorder. Indeed he has hyponatraemia, alongside hyperkalaemia. This, in addition to a postural drop, would make one very suspicious of adrenal insufficiency. This is confirmed by one of two factors: buccal pigmentation (pathognomonic for Addisons). An inadequate response to ACTH stimulation would be indicative of adrenal insufficiency.
