Consultation note
Time in:
MR#:
Patient Name:
Date of Birth:

Dr. ___________ has asked for consultation on this patient regarding regarding Primary Adrenal Insufficiency.

Thank you for inviting us to see this patient.

Chief complaint: ___ year old male/female presents today for evaluation and treatment of Addison's Disease. Patient complains of the following:
weakness, muscle weakness, fatigue, weight loss, anorexia/nausea/vomiting, lethargy, confusion, abdominal pain, diarrhea, constipation, dehydration, salt wasting, salt craving, poor response to stress, amenorrhea, 16% syncope, patchy altered skin coloration, excessive sweating (face or palms), headache, palpitations, tremor, seizures, sleeping difficulty, agitation, labile mood, attention deficit, amnesia, hallucinations, unconsciousness

My key findings of the ROS, Past Hx, Family Hx, and social Hx are:
ROS: Review of 12 systems was negative with exception of those things mentioned above in the HPI and weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Patient denies weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Past Medical History:

Past Surgical History:

Family History:

Social History:
Diet:
Exercise:
Smoking:
Recreational Drug use :
Education:
Occupation:
Lives with ____ where ____

Home Meds:

Allergies:

My key findings of this patient's Physical Exam are:
VITALS:
Pulse:
Blood Pressure:
Respirations:
Temperature:
Weight:
Height:
BMI:

GENERAL: sitting up/reclined in bed, awake, alert, and oriented, hypotension especially postural, decreased extracellular volume, decreased cardiac output, wasting
occasionally decreased androgen dependent hair (pubic, axillary) and protein anabolism in women, excessive irritability and restlessness, occasionally psychosis
HEAD: normocephalic, atraumatic, no temporal wasting, negative chvostek sign
NOSE, MOUTH: lips and mucous membranes are moist, normal color of buccal mucosa, bluish-black patches on mucous membranes
EYES: EOMI, PERLA, no proptosis
NECK: supple, thyroid normal in size, thyroid small, thyroid low set, no thyromegaly or masses
RESPIRATORY: clear to ascultation bilaterally
CARDIOVASULAR: S1S2, no murmurs/rubs/gallops
GI: soft, non-tender, + bowel sounds
LYMPHATIC: no cervicoclavicular adenopathy appreciated
MUSCULOSKELETAL: moving all extremities
EXTREMITIES: no edema present
NEUROLOGIC: monofilament sensed in all areas of the foot, vibratory sensation intact, fine/crude touch intact, pulses palpable, DTRs 2+, CN grossly intact
DERMATOLOGY: no xanthomas appreciated, no skin ulcers, no calluses, no onchyomycosis/dermatophyosis, no striae, hyperpigmentation of skin, buccal mucosa, surgical scars, palmar creases, elbows, knees, knuckles, perianal mucosa, around areolas of nipples, diffuse brown, tan or bronze darkening of both exposed and unexposed areas, vitiligo
PSYCHIATRY: patient answers questions appropriately, appropriate affectcoherent thoughts without flight of ideas

Labs:

Assessment:

Causes:
Most common cause is idiopathic adrenalitis/atrophy (probably autoimmune), also caused by bilateral tuberculosis (10% cases, used to be 70-90% cases), adrenalectomy, other chronic granulomatous diseases - histoplasmosis, coccidioidomycosis, cryptococcosis, other less common causes - amyloidosis, sarcoidosis, adrenal infarction (arteritis, thrombosis), hemochromatosis, fungal infections, syphilis, AIDS-induced CMV (other causes in AIDS include Mycobacterium avium-intracellulare, cryptococcus, Kaposi's sarcoma, rifampin, phenytoin, ketoconazole, opiates), bilateral hemorrhage (anticoagulant, trauma, coagulopathies, pregnancy, hemophilia, sepsis, infection), metastatic carcinoma, post-op metabolic failure in hormone production - congenital adrenal hyperplasia, enzyme inhibitors (metyrapone, ketoconazole, aminogluteinimide), cytotoxic agents (mitotane)
Pathogenesis:
Progressive adrenocortical destruction of at least 90% adrenal glands before clinical signs appear, probably autoimmune, 50-75% auto Ab against adrenal glands.
Complications:
Acute exacerbation if stress (addisonian crisis, adrenal crisis, acute adrenal failure), arrhythmia from hyperkalemia, poor response to stress
Associated conditions:
Some patients have Ab to thyroid, parathyroid and/or gonadal glands, other autoimmune diseases - hypoparathyroidism, mucocutaneous candidiasis, chronic lymphocytic thyroiditis (Hashimoto's disease), premature ovarian failure, diabetes mellitus type 1 (IDDM), Graves' disease, hypopituitarism, pernicious anemia, testicular dysfunction, dermatitis herpetiformis, vitiligo, myathenia gravis
polyglandular autoimmune syndrome (hypoparathyroidism, vitiligo, pernicious anemia); also called autoimmune polyendocrine syndrome (APS) type I - combination of parathyroid and adrenal insufficiency and chronic mucocutaneous candidiasis; associated with pernicious anemia, chronic active hepatitis, alopecia, primary hypothyroidism, premature gonadal failure; autosomal recessive; usually presents in childhood. APS type II - consists of 2 or more of: Hashimoto's disease, premature ovarian failure, type 1 diabetes, Graves' disease; also associated with pernicious anemia, vitiligo, alopeica, nontropical sprue, myasthenia gravis; mutant gene on chromosome 6, associated with HLA-B8 and -DR3; presents in adulthood
Also, seen in chronic lymphocytic thyroiditis (Hashimoto's disease) with or without type 1 diabetes in Schmidt's syndrome.

Diagnostic Plans:
Screening test for primary adrenal insufficiency: measure baseline cortisol, give cosyntropin (synthetic ACTH) 0.25 mg IV or IM, measure plasma cortisol after 30-60 minutes. If rise in < 7 mcg/dl and basal cortisol level < 20 mcg/dl this indicates adrenal insufficiency. Checking ACTH and aldosterone can help differentiate primary from secondary. In primary adrenal insufficiency - high ACTH, subnormal aldosterone increment. In secondary adrenal insufficiency or normals - low-normal ACTH, normal aldosterone increment. If clinically highly suggestive of adrenocortical insufficiency, before test and each day of 3 day test - collect 24-hour urine 17-OH steroids (can also measure urine cortisol and 17-ketosteroids) and creatinine (to evaluate adequacy of collection).
Give dexamethasone 0.5 mg IV twice daily plus fludrocortisone 0.1 mg PO once daily, ACTH 0.4 mg mixed in 500 ml D5NS infused over 8 hours each day of test. If normal response or secondary insufficiency - increased 17-OH each day, in Addison's disease - no increase or small increase, urine and blood steroid values overlap normal range in mild adrenal insufficiency.
If the etiology is possibly adrenoleukodystrophy labs would reveal excessive levels of very long-chain fatty acids, and ACTH insensitivity would be present.

Therapeutic Plans:
Liberal sodium intake, carry medical identification, learn parenteral self-administration of steroids.
Maintenance steroids: hydrocortisone 30 mg/day PO, 15-20 mg in am, 5-10 mg at night (alternatives - dexamethasone 0.5 mg daily, prednisone 5 mg am, 2.5 mg at night; cortisol 20 mg am, 10 mg at night cortisone dosage varies from 12.5-50 mg/day, most 25-37.5 mg/day, take with meals, milk or antacids)
Replacement dose steroids in crisis or when stressed e.g. surgery - (3x the dose for 3 days).
reduce dose if side effects (insomnia, irritability, mental excitement), hypertension, diabetes mellitus, active TB
Fludrocortisone 0.05-0.2 PO mg/day, ensure ample sodium intake, monitor blood pressure (should be normal without postural change) and electrolytes, complications - hypokalemia, edema, hypertension, cardiomegaly, congestive heart failure (sodium retention), increased fludrocortisone and excess salt in diet if exercise with sweating, extremely hot weather, GI upsets
parenteral steroids if diarrhea or vomiting.
DHEA appears to improve symptoms in adrenal insufficiency; androgenic adverse effects in women, increased prostate cancer cell proliferation in men; other reported adverse effects include hepatic dysfunction, hypertension, acute mania and palpitations; DHEA inhibits CYPA34 in vitro so may have many drug interactions; purity and potency of commercially available formulations unknown. DHEA improved well-being and sexuality in women with adrenal insufficiency in small randomized crossover study; 24 women with adrenal insufficiency (14 primary, 10 secondary) given in random order dehydroepiandrosterone 50 mg vs. placebo PO once daily for 4 months each with 1-month washout in-between; dehydroepiandrosterone significantly improved overall well-being and scores for depression and anxiety and increased frequency of sexual thoughts, sexual interest and satisfaction with sexuality (N Engl J Med 1999 Sep 30;341(14):1013), editorial can be found in N Engl J Med 1999 Sep 30;341(14):1073 DHEA 50 mg PO daily for 12 weeks associated with improved self-esteem, mood and fatigue and tendency for improved overall well-being in randomized placebo-controlled crossover trial of 39 patients with Addison's disease (J Clin Endocrinol Metab 2000 Dec;85(12):4650)

Patient Education:
Return to Clinic:
We have discussed our diagnostic and treatment plans with the patients and family/friends that were present. All questions have been answered to the patient's satisfaction.

Thank you for inviting to see this consult!

Written by ___ _____________________ Time out_______