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

Dr. ___________ has asked for consultation on this patient regarding regarding secondary adrenal insufficiency.

Thank you for inviting us to see this patient.

Chief complaint: ___ year old male/female presents today for evaluation and treatment of secondary adrenal insufficiency. Patient complains of the following:
weakness, fatigue, anorexia, nausea, weight loss

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
HEAD: normocephalic, atraumatic, no temporal wasting, negative chvostek sign
NOSE, MOUTH: lips and mucous membranes are moist, normal color of buccal mucosa
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
PSYCHIATRY: patient answers questions appropriately, appropriate affectcoherent thoughts without flight of ideas

Labs:

Assessment:

Causes: The most common cause is high-dose and/or long-term glucocorticoids use. Other causes are pituitary tumors, Sheehan's syndrome, other pituitary lesions, hypothalamic lesions.
Pathogenesis: decreased ACTH, poor response to stress
Possible risk factors: adrenal failure reported as rare complication of antiphospholipid antibody syndrome in children, case report noted 4 previous case reports (Thrombosis Journal 2005 Apr 18;3:6)
Associated conditions: hypogonadism, amenorrhea, hypothyroidism
Rule Out: tuberculosis (TB), metastatic cancer, for postural hypotension - #1 drugs, #2 diabetes, hypoproteinemia - cause of decreased serum total cortisol

Diagnostic Plans:
CBC, ACTH, cortisol, aldosterone, SMA-7, FSH, TSH, T4, RT3, testosterone (males)
Low-dose corticotropin stimulation test (using cortisol response 30 minutes after Synacthen 1 mcg) sensitive for secondary adrenocortical insufficiency; prospective study of 72 Chinese patients with suspected secondary adrenocortical insufficiency, cortisol > 550 nmol/L was optimal cutoff using insulin tolerance test as gold standard; low-dose corticotropin stimulation test had 97% sensitivity, 78% specificity, 81% positive predictive value, 97% negative predictive value, positive likelihood ratio 4.4 and negative likelihood ratio 0.04 (Hong Kong Med J 2002 Dec;8(6):427 in JAMA 2003 Mar 19;289(11):1353)
Initial testing:
Cortisol before and after 1 mcg adrenocorticotrophin
Cortisol before and after 250 mcg adrenocorticotrophin
Confirmatory testing:
Cortisol before and after 48 hour infusion of adrenocorticotrophin
Cortisol, adrenocorticotrophin (ACTH) and glucose before and after insulin-induced hypoglycemia
Cortisol and adrenocorticotrophin (ACTH) before and after corticotropin releasing hormone (CRH)
Monitoring testing - sodium, potassium, bicarbonate
Blood tests: should reveal decreased ACTH and related peptides, decreased cortisol, normal or increased aldosterone, no change in cortisol with cortrosyn, decreased PMN, decreased Hb, decreased RBC, increased lymphocytes, increased eosinophils, fasting hypoglycemia, volume overload, dilutional hyponatremia, normal K+, hypoproteinemia associated with lower serum total cortisol levels, even if normal adrenal function.
Cosyntropin test has high sensitivity for primary adrenal insufficiency but lower sensitivity for secondary adrenal insufficiency. Hypothalamus stimulation tests needed if negative cosyntropin test and high suspicion of secondary adrenal insufficiency.
Urine studies: decreased urinary 17KS, 17OH

Therapeutic Plans:
Maintenance steroids: hydrocortisone 30 mg/day PO, 15-20 mg in am, 5-10 mg at night (alternatives - prednisone 5 mg in am, 2.5 mg at night; cortisol 20 mg in am, 10 mg at night; dexamethasone 0.5 mg qd, cortisone dosage varies from 12.5-50 mg/day, most 25-37.5 mg/day) take with meals, milk or antacids except for gastritis. Reduce dose if side effects (insomnia, irritability, mental excitement), hypertension, diabetes mellitus, active TB.
Fludrocortisone 0.05-0.2 PO mg/day if necessary, 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). Replacement-dose steroids in crisis or when stressed e.g. surgery; cortisol 75-150 mg/day
stress dose hydrocortisone may facilitate ventilator weaning in critical care patients with adrenal insufficiency.
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 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
Surgery: perioperative hydrocortisone on day of surgery - 100 mg before, 100 during, 100 after, and taper over 3-5 days to pre-op dose. There is insufficient evidence to support or refute perioperative use of high-dose glucocorticoids in patients on chronic steroids to prevent perioperative hypotension.

Patient Education:
Return to Clinic:
Medic Alert Bracelet
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_______