1. Sample Case Presentation Agatha Stanek July 10, 2010

2. 33 year- old Caucasian female presents to clinic with her younger sister complaining of vomiting, a loss of appetite, and chronic diarrhea over the last 6 days. Patient reports dizziness, hair loss, and abdominal pain. Decreased cold tolerance Rapid weight loss Patient confides in physician that she feels lost and like life is not worth living anymore; she has no strength to live. Case presentation

3. PMH Appendicitis treated surgically 10 years ago Pernicious anemia x 5 years Formally diagnosed with anorexia nervosa at age 19 and treated successfully

4. N o family history of cancer Father died of cardiac arrest 7 years ago Mother has Crohn disease x 22 years. Crohn disease also runs in father’s side of the family- grandfather had disease. Sister of patient has Graves disease Occupational Hx Patient recently moved from California to Ottawa where she is now staying with younger sister and her family. Upper class citizen who has a successful advertising company- very stressful Fx

5. Denies tobacco or alcohol use No children Sister speaks to you outside and reveals that the patient is back in Ottawa after a messy divorce from her husband. She worries that the patient is depressed or she is becoming anorexic again as she has stopped eating.Meds Cyanocobalamin, 200 µg IM; monthly. Increased dosage by physician back in the USA. No allergies Sx

6. no recent changes in vision, no fevers, chills, dyspnea, cough or night sweats changes in menstrual cycle Reports aches and pains Admits to having one fainting spell 2 weeks ago (+) for weight loss of 15 pounds in the last month Patient is quite tanned, although she reports significant exposure to the sun ROS

7. VS: BP: 95/75, P 83/min sittingT: 37 °C BP: 80/60, P 110/min, standingHT: 5 ft- 8 ½ in RR: 14/minWT: 121 lbs SKIN: Intact, warm, quite dry HEENT: PERRLA EOMI Normal funduscopic exam Dry mucous membrane PE Results

8. NECK Thyroid normal, no masses Shotty lymphadenopathy?? LUNGS Clear; normal vesicular and bronchial sounds CARDIAC RRR ABD Soft but not tender (-) hepatosplenomegaly GU Normal pelvic exam MS/ EXT Normal range of motion Muscle strength throughout NEURO Alert and oriented Normal gait CNS II- XII intact

9. Anorexia nervosa/ Severe nutritional deficiencies Depression Colon disease… Infection Pituitary failure/ hypothalamic tumour Differential Diagnosis

10. Laboratory Blood Test Results

11. UA: Clear and yellow SG 1.1016 pH 6.45 (-) blood Antibody Testing: (+) 21- hydroxylase (-) 17-hydroxylase (-) C-P450 Peripheral Blood Smear: Normal, normocytic erythrocytes Additional Tests

12. Why are these tests results significant???

13. Autoimmune Addison disease (AD) - Why autoimmune? - Why is shotty lymphadenopathy consistent with this diagnosis in this particular patient? - Why was the patient anemic? - What other imaging test can confirm this test result? - CT scan: which revealed moderate bilateral atrophy of the adrenal glands. - MRI Diagnosis

15. No cure for AD Glucocorticoid and possibly mineralocorticoid replacement therapy Hydrocortisone- daily oral dose of 15-25 mg in 2 doses; 2/3 in the am and 1/3 in the pm. Proper dose results in normal differential WBC count. Fludrocortisone- daily 0.05-0.3 mg orally No restrictions on physical activity required Diet: include at least 150 meq of Na daily; more if excessive sweating/ diarrhea occur Treatment

16. Proper control results in a good long-term prognosis and normal life expectancy Complications: Addisonian crisis Cushing syndrome Neurologic disease Life-threatening systemic infection? Serious Complications and Prognosis

17. Suggest colonoscopy to rule out… Recommend outpatient therapy- counselling. Referral to nearby psychologist. Further Recommendations