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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the clinical presentation, symptoms, and laboratory changes associated with Addison disease.

  • Optimize pharmacologic and nonpharmacologic therapy for patients with Addison disease and comorbid conditions.

  • Provide education and counseling to patients and family members about Addison disease and the proper administration, side effects, and adverse effects of corticosteroids and mineralocorticoids, and the importance of adherence to therapy.

  • Provide counseling and education about common side effects associated with high and low cortisol serum concentrations.

  • Compare corticosteroids with respect to relative glucocorticoid and mineralocorticoid potencies.

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PATIENT PRESENTATION

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Chief Complaint

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“I’ve noticed that over the past six months, my son’s skin is getting darker, and he has been more lethargic, somewhat withdrawn, and sleeping more. I have also noticed that he has been making some poor choices, in terms of friends and activities.”

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HPI

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Gregory Waters is a 19-year-old man who is brought to the ED by his mother after she finds him crying, confused, and disoriented. His mother states that she has recently noticed that he has not had the same level of energy, and has been complaining about not being able to run and play basketball with his friends at the park. She has also noticed he has been hanging out with a different group of friends, and she is concerned he may be involved in some abhorrent activities and may not be taking his medications appropriately.

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PMH

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  • Type 1 DM × 7 years

  • Hypothyroidism × 3 years

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FH

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Mother, 52 years old, has HTN; father, 54 years old, has hypothyroidism; sister, 24 years old, has both HTN and type 1 DM

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SH

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Denies use of alcohol, tobacco, or illicit drugs; lives with his mother

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Meds

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  • Lantus 24 units subcutaneously at bedtime

  • NovoLog 1:15 scale carbohydrate counting ratio, subcutaneously with meals

  • Levothyroxine 100 mcg PO daily

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All

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NKDA

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ROS

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Increased tanning of the skin noted over the past 6 months. Increased fatigue, nausea, and a 2.5-kg weight loss over the past month.

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Physical Examination

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Gen
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Alert, somewhat disoriented and confused

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VS
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BP 84/47 mm Hg, HR 91 bpm, RR 16/min, T 36.2°C; Wt 62.5 kg, Ht 5′4″

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Skin
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Warm, dry, and intact. Slightly tanned color

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HEENT
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Normocephalic; oral mucosa moist. PERRL. EOMI

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Neck
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No JVD. Nontender. No thyroid nodularity

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Lungs
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CTA. Respirations are ...

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