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You are an FY1 doctor working on the Acute Medical Unit at your local hospital. Dermot Itis is a 49 year old gentleman who has presented to the unit, complaining of nausea and vomiting. He has also been experiencing some dizziness.

Dermot gives you his handwritten medication list, which includes:

Cetirizine Istin Hydrocortisone

Please take a history from Dermot and perform the relevant examination. You will then be asked to discuss your differential diagnosis and management plan.

You are Dermot Itis, a 49 year old gentleman who hasn’t been feeling very well for the past week or so. You work as a janitor at a primary school, and you’re sure you’ve picked up something from one of those kids again…

HPC: You first started feeling sick about five days ago. You were nauseous and began to vomit. At first this was awful – you were vomiting once every two hours. By the end of the second day, you were simply sprawled on the bathroom floor and wretching. It didn’t feel very nice!

The vomit was originally normal colour: with some carrots from your dinner the night before. However, because you’ve been feeling sick, you haven’t eaten anything for the last five days. At the moment you’re just about managing sips of water. You do have a real craving for pretzels or salty chips, though! You have also been experiencing dizziness. You think that this is due to not eating: it’s making you feel weak. In fact, yesterday when you rushed to the toilet to be sick, you were so dizzy you fell onto your knees and hit your head on the plastic side of the bath. It wasn’t very painful, mind, and you don’t think the bump was that bad. You did lose consciousness for a few seconds though, and can’t quite remember falling.

In terms of other problems that you have been experiencing this week, the main one is probably the confusion. You are normally a little forgetful, but it has been ridiculous this week. You keep wandering into a room and forgetting why you went in. Your sister, who lives in Australia, claims that you have called her at least twice ‘to ask about the kangaroos’. You don’t believe her, but you guess that it will show up in your phone bill! She also said you sounded very irritable and snappy, which is not like you at all: you’re normally a really down to earth person. You have had occasional loose bowel motions, but this is not as bad as the vomiting. There is no blood in the stool and no mucus.

PMH: You have a long term medical condition, called Addison’s disease. This was diagnosed years ago and never really bothered you. You haven’t been able to take any of your normal medicines over the past 5 days, since you haven’t been keeping anything down. You’re normally really good with your tablets, but aren’t really fussed about not taking them this time. A week off the tablets can’t do much harm, can it? You also have some high blood pressure.

DH: You take two small tablets for the Addison’s, you think they’re steroids. You also take a tablet for your blood pressure – you hope that hasn’t gone up too much whilst you’ve been unwell! Occasionally you have a hayfever tablet too, but it’s not hayfever season at the moment, happily.

SH: You live by yourself in a small flat in the local village. You work in the local primary school as a janitor, but obviously haven’t been able to go to work whilst you’ve been unwell. You don’t think you’ve eaten anything unusual lately to make you be sick, and haven’t been abroad in years. You did go on holiday last month. This was to Hull.

ICE: You heard that one or two of the kids had ‘tummy bugs’, so you guess that you picked up an infection from them. You hope that your blood pressure isn’t too high, and want that checked out. You reckon that the dizziness has been caused by not eating and being sick a lot.

FH: No one in your family is really around anymore. Your sister is in Australia – you know that she has diabetes. You don’t think your parents had any long term medical problems other than emphysema.

The student should demonstrate a history which identifies the clear risk of Addisonian Crisis in this patient. It would be relevant to screen for source of infection in this gentleman, however the focus should be on identifying features of Addison’s disease and exploring this gentleman’s compliance with drug therapy.

The student’s differential diagnosis should sound something like:

“My differential diagnosis would include an endocrine cause: more specifically Acute Exacerbation of Primary Hypoaldrenalism or Addison’s Disease, secondary to withdrawal of maintenance therapy due to gastroenteritis. I would therefore wish to rule out an Addisonian Crisis in this gentleman. Other endocrine causes would be important to investigate, including diabetes mellitus and thyroid disorders, due to their link with Addison’s disease. Finally, due to the clear infective symptoms, it would be important to identify the source of this infection and treat accordingly.”

Example questions for discussion may include:

  • What is Addison’s disease?
  • How would you investigate this patient in the acute setting?
  • How would you manage this patient acutely?
  • How would you confirm a diagnosis of Addison’s?
  • What ongoing monitoring would this patient require?
  • What are the signs of an Adrenal Crisis?
  • What are the complications of long term steroid therapy?