A 32 year old male presents to your office for initial evaluation. He is a busy

Question

A 32 year old male presents to your office for initial evaluation. He is a busy systems analyst for a computer manufacturer who travels a lot, and puts in many hours of work with inadequate rest. He is mildly obese but continues to have a poor diet. He eats fatty foods and does not exercise, aside from when he is running late to an appointment. He snacks often on salty foods. For the past two months, he complains of feeling weak, and occasionally experiences light-headedness and dizziness that is accentuated when rising from a supine position. Eventually, his appetite begins to wane and he starts to losing weight. He is having common episodes of diarrhea. His colleagues and friends notice that he looks tan, despite spending little time in the sun. He complains about cold weather and tries to avoid cold climates and temperatures. He is considering relocating to a warmer region.

When attending a meeting in Denver, he presents to the ER complaining of feeling weak; congestion in his head and chest; and severe abdominal, back, and leg pain. His blood pressure is 70/50 mmHG, respiratory rate is 20. Appropriate labs are ordered.

Results:

Sodium= 120 mEq/l

Potassium-6.0 mEq/l

Ratio of serum Na:K= 25:1

Hematocrit= 59

WBC count= 6000

Decreased plasma cortisol and aldosterone

Urine shows increased excretion of Na and decreased excretion of K

Low levels of hydroxycorticosteroids

What might be causing the pain in the abdomen, back, and legs? Why?

The viral infection poses a kind of stress. Why might the patient have such a severe reaction?

How do the abnormal Na and K levels relate to adrenal function?

Explain the reasons for the elevated hematocrit level.

Why would one see this result in the urine if the adrenal gland is malfunctioning?

What is your diagnosis?

What is ACTH?

Explain why the ACTH level remains elevated.

Why would extra salt intake be appropriate following vomiting or diarrhea?

Explanation / Answer

The symptoms indicate Addisons disease. The disease results from adrenal malfunction.

* the pain in the abdomen, back, and legs is due to electrolyte imbalance. The imbalance results from diarrhea and vomitting

* The viral infection makes the person immuno compromised

* The aldosterone secreted by adrenal glands normally promote retention of sodium ions and excretion of potassium ions. Decreased levels of aldosterone results in excretion of Na+ and retention of K+ ions

* The elevated levels of hematocrit is due to hypovolemia, which might have resulted from diarrhea

* Adrenal gland malfunction leads to decreased aldosterone production. This inturn affects the electrolyte balance in the serum

* The diagnosis is Addisons disease

* ACTH = Adreno corticotrophic hormone. The secretion of ACTH is regulated through a negative feed back mechanism. Hypertrophy or destruction of adrenal cortex prevent release of glucocorticoids which provide the negative feed back control. As a result, ACTH is continuously secreted and its levels in serum rise

* To replace the lost electrolytes, sodium and potassium must be given. If not given, it worsens the situation of electrolyte imbalance and may be fatal

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