Question

A 37 year old man presents to the triage desk of the ER where you work. He is tall, thin, pale, and has dry and flaky skin. He has rapid shallow respirations and seems to have difficulty focusing on your questions. Your quick assesment is:
Patient Values Normal Values
Heart rate 140 bpm 60-100 bpm
Pulse Quality Regular, thready, weak Strong, regular
Respiratory rate 25 beats/min 12-18 breaths/minute
Blood Pressure 92/55 mmHg Systolic: 100-120 mmHg
Diastolic 60-80 mmHgh

You immediatley admit him to the hospital and start IV fluids. Before you start the fluids, you draw blood to analyze in your I-Stat (besides chemistry analyzer) and you send it to the lab.

Laboratory results:

Patient Values Normal Ranges
Blood glucose 70 mg/dL 80-120 mg/dL
serum sodium 125 mEg/L 135-145 mEg/L
Serum potassium 6.2 mEg/L 3.5-5.0 mEg/L
TSH 3.5 uU/ml 0.5-4.5 uU/ ml
T3 80 ng/dl 60-180 ng/dL
T4 9.2 uU/ml 4.5-11.5 uU/mL
ACTH 75 pg/mL 9-52 pg/ml
Cortisol 1.8 mg/dL 6-23 mg/dL

1.) Make a list of this man's significant medical problems and abnormal lab values.
2.) Propose a single underlying cause to explain these problems. List the problems that can be associated to this proposed underlying cause. For each item on your list, briefly, (a short phrase), explain how that problem (or abnormal value) is related to others.

Answer 1

Answer:

1.) Abnormal parameters:

• Difficulty focusing (confusion)
• Elevated heart rate (tachycardia), with thready and weak pulse quality
• Elevated respiratory rate (tachypnea). Rapid and shallow respiration.
• Low blood pressure (hypotension)
• Low blood glucose (hypoglycemia)
• Low serum sodium (hyponatremia)
• High serum potassium (hyperkalemia)
• High ACTH
• Low cortisol (hypocortisolism) (Note: this lab values are obtained normally at 8am, due to its physiological curve)

2.) Addison’s disease

• Confusion: Hyponatremia causes confusion, due to neuronal imbalance.
• Tachycardia: Inmediate response to hypotension, so as to maintain a adequate cardiac output.
• Tachypnea: Hyperkalemia produces an acid-base imbalance (acidemia), which normally can be compensated by changes in the respiratory rate.
• Hypotension: hyponatremia produces reduced water retention in blood vessels, affecting blood pressure
• Hypoglycemia: hypocortisolism directly affects blood glucose (decreased gluconeogenesis)
• Hyponatremia: Sodium retention will be reduced due to the absence of Aldosterone,
• Hyperkalemia: Potassium excretion will be reduced due to the absence of Aldosterone.
• High ACTH: No negative feedback inhibits the production of ACTH (depends on cortisol level).
• Hypocortisolism: Due to the non functioning cortex of adrenal gland, no cortisol is being produced.

Explanation:

Addison’s disease, also known as adrenal insufficiency, is a set of characteristic signs and symptom caused by the failure of the adrenal gland to produce steroid hormones, mainly Cortisol and in some cases Aldosterone.  This syndrome presents various causes, incluiding autoinmune disease, infectious, and infiltration by cancerous cells.