[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]”This patient has presented to A&E following a fall. Please assess them clinically and discuss your findings with the examiners.”[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/149509060″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”8″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”2″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][/vc_column][/vc_row]
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This patient has hyperpigmented lesions in their mouth and a small patch of vitiligo on their hands. The unifying diagnosis is Addison’s disease.
Addison’s disease is characterized by adrenocortical insufficiency which is due to abnormal function or damage to the adrenal cortex. The result is the lack of the glucoacorticoid, cortisol secretion as well as the mineralocorticoid aldosterone. The symptoms appear when more than 90% of the adrenal cortices have been destroyed or have become dysfuntional. The clinical features depend on whether the onset is acute or chronic. Precipitating factors of the disease include infection, surgical intervention, trauma, vomiting/diarrhoea, and prolonged steroid use.
Presentation of acute Addison disease – Addisonian crisis
In acute cases, the patient presents in state of shock and may have altered level of consciousness with marked nausea, vomiting, abdominal symptoms and low blood pressure. There may be high grade fever touching 38 dgerees centigrade or higher.
Presentation of chronic Addison disease
In chronic Addison’s disease, the onset is gradual and symptoms are often non-specific. Cutaneous and mucous hyperpigmentation are the early manifestations and more commonly seen in areas which are exposed to the sun, on extensor surfaces, knees, elbows, and knuckles. Other areas include creases of the palm, nail beds, oral cavity’s mucous membranes, and mucosa of the vagina and perianal region. Vitiligo may also be seen in autoimmune cases. General symptoms include weakness, easy fatigability, loss of appetite, and weight. There may be GI symptoms such as nausea, vomiting, occasional diarrhea and glucocorticoid-responsive steatorrhea.
Orthostatic hypotension leading to syncope is also seen. Not only this, myalgias and flaccid paralysis of muscles have been reported. Other symptoms include pain in joints and muscles while special senses become heightened. Insulin sensitivity may be seen in diabetics and impotency in those with already compromised testicular activity. Females may present with amenorrhea due to progressive loss of weight and deteriorating health status. The gonadal function may be impaired due to steroid-responsive hyperprolactinemia leading to amenorrhea. There may be no or minimum axillary and pubic hair and less body hair in female patients because lack of adrenal androgens.
Identify and treat any underlying casue that can be treated, with adrenal replacement of both mineralocorticoid and glucocorticoid replacements. Also advise patients, during any inter0current illness, to double their oral doses.
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