[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_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has Addison’s disease.

The clinical signs exhibited in this video include:

  • Pigmented lesions in the oral mucosa;
  • Hyperpigmented skin creases in the palms;
  • A small patch of vitiligo on the dorsum of the hand (vitiligo is associated with Addison’s disease but not caused by it).

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]Adrenal insufficiency is a disorder characterized by insufficient production of the glucocorticoids and mineralocoricoids by adrenal glands. It can be divided into:

  • Primary adrenocortical deficiency (Addison disease)
  • Secondary failure in elaboration of ACTH

Addison disease is a slow, progressive disease due to adrenocorticoid hypofunction, which in turn could be due to a number of causes. These causes include:

  • Secondary to anatomic destruction of gland due to:
    • Idiopathic atrophy (most common)
    • Autoimmune mechanisms
    • Surgical removal
    • Infection (TB, cytomegalovirus, fungal)
    • Trauma
    • Haemorrhagic
    • Metastatic invasion
  • Metabolic failure secondary to:
    • CAH
    • Enzyme inhibitors
    • Cytotoxic agents

Clinical features of the disease develop gradually, often over a period of months and include:

  • Weakness
  • Paresthesias
  • Cramping
  • Stress intolerance
  • Irritability
  • Personality changes
  • Restlessness
  • Skin hyperpigmentation
  • Arterial hypotension (hypostatic)
  • Abnormal GI function:
    • Nausea and vomiting
    • Mild anorexia
    • Weight loss
    • Diarrhoea
    • Abdominal pain
  • Chronic form is characterized by:
    • Sparse axillary hair
    • Weight loss
    • Small heart

At times signs and symptoms of the disease have a sudden onset leading to a crisis and emergency which could prove to be fatal as well. This acute adrenal failure is called Addison crisis and is characterized by:

  • Fever
  • Hypotension
  • Severe vomiting and diarrhea (dehydration)
  • Loss of consciousness
  • Hyponatremia
  • Hyperkalemia
  • Mild acidosis

The most important risk factor for adrenal crisis in a person with Addison disease is gastric infection. Other factors include:

  • Diabetes
  • Asthma

Diagnosis of Addison disease depends on the assessment functional capacity of adrenal cortex to produce cortisol. Investigations carried out include:

  • Cosyntropin or ACTH stimulation test
  • Rapid ACTH test
  • Metabolic profile
  • CBC
  • Liver function tests
  • Renal function assessment (Urea, creatinine and electrolytes)
  • TSH
  • Auto-antibody testing
  • Prolactin testing
  • Chest radiograph
  • Abdominal CT scan
  • ECG
  • Sputum examination
  • Gastric washing examination
  • PPD

Management of Addison disease involves pharmacotherapy aiming at reducing morbidity and preventing complications. In addition to patient education glucocorticoids and mineralocorticoids are supplemented as physiological doses.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has Addison’s disease.  They have hyperpigmented lesions in the oral mucosa and skin creases of the palms.  I also noted a small patch of vitiligo which is associated with Addison’s on the dorsum of their hand.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]