Station 46
Laura Green
Age: 26 years old female
Full Case
Patient’s Data
Patient’s name: Laura Green
Age: 26-year-old female
Past medical history
- Nil
Drug and Allergy History
- Nil
Recent notes/consultation
Seen by Dr Anita Nweke (Clinical practitioner access role) 2 days ago
Presenting Complaint: Patient reports been tired all the time which is associated with malaise and weight loss. No red flags.
Examination: BP 90/59. Pulse 99bpm. Weight 57kg (Previously 63kg)
Plan: Bloods, review with results
Results of patient’s bloods—yet to be filed
Laboratory Test Results
| Test | Result | Normal Range |
|---|---|---|
| Potassium | 5.8 mmol/L | 3.5 – 5.0 mmol/L |
| Sodium | 130 mmol/L | 135 – 145 mmol/L |
| Blood Urea Nitrogen (BUN) | 12 mg/dL | 7 – 20 mg/dL |
| Creatinine | 1.0 mg/dL | 0.6 – 1.2 mg/dL |
| Glomerular Filtration Rate (GFR) | >90 mL/min (normal) | >60 mL/min (normal) |
Other Tests: TFTs, FBC, Ferritin, Coeliac screen, LFTs, HbA1c, CRP, and Vitamin D — all within normal range.
Note: Patient has booked a follow-up telephone consultation to discuss her blood test results.
Patient's Story (Role player’s brief)
Patient’s Story
You are Laura Green, a 26-year-old woman calling to discuss your recent blood test results.
You had these tests done because over the past 2 weeks, you’ve been experiencing fatigue, muscle weakness, and occasional dizziness (Lightheaded like you want to pass out). Despite sleeping through the night, you still feel exhausted during the day. You’ve also noticed a significant loss of appetite, and although you haven’t checked your weight, your clothes are noticeably looser and no longer fit properly.
In addition, you’ve observed that your skin appears darker than usual, which is new for you.
You’re not taking any over-the-counter medications, supplements, or prescribed treatments.
Social History: You work as a police officer, but you are currently off work due to how unwell you’ve been feeling. You live with your boyfriend, who is with you during this phone consultation. You do not smoke or drink alcohol. You do not also take illicit drugs
Idea: You suspect it could be low iron, since it’s common in women and often causes tiredness.
Concern: Your symptoms are now affecting your ability to work.
Expectation: You’d like the doctor to explain your test results and let you know what’s going on
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about when the fatigue started and whether it’s getting better, worse, or staying the same
- Ask about associated symptoms such as muscle weakness, dizziness, or light-headedness (to assess impact and possible electrolyte-related symptoms)
- Ask about any nausea, vomiting, or abdominal symptoms (possible signs of adrenal insufficiency or systemic illness)
- Ask about any changes in appetite and unintentional weight loss
- Ask about any darkening or changes in skin colour (can indicate Addison’s disease)
- Ask about chest pain or palpitations (to assess possible hyperkalaemia complications)
- Ask about salt craving or whether the patient has noticed an increase in craving for salty foods (important in the context of suspected adrenal insufficiency)
- Ask about any existing medical conditions not listed in the notes/medical records
- Ask about current medications, over-the-counter supplements, or herbal remedies
- Ask about any recent changes to diet or exercise routine
- Ask about family history of any medical problems, such as Addison’s disease or autoimmune disorders
- Ask about social lifestyle, including occupation, smoking, alcohol, and recreational drug use
- Ask about mood and emotional wellbeing, including any recent stress at work or home
- Ask how the condition has affected her at work and at home (to assess impact on daily functioning)
- Explain that the results show hyperkalaemia and hyponatraemia, a combination that raises suspicion for Addison’s disease.
Example of explanation to patient
Laura, your blood test shows that the level of salts in your body isn’t quite right. The one called Potassium is raised and the one called sodium is low.
When we see this pattern, together with your symptoms, it can mean that a part of your body called the adrenal glands whichsits on top of your kidneys and help control your energy, blood pressure, and salt levels, might not be working properly.
One possible cause is a condition called Addison’s disease.
Because of the low blood pressure and the changes in your blood salts, I think it’s safest for you to be seen in hospital today. They’ll be able to give you fluids through a drip to help balance your levels and do more tests to confirm what’s going on.
Are you with someone right now who can take you to hospital — maybe your partner or a friend? I wouldn’t recommend going alone. Please make sure they know what’s going on, and if anything changes or you feel worse on the way, stop and call 999.
In hospital, if Addison’s is confirmed, you may be started on lifelong steroid treatment to replace the hormones your body isn’t making enough of. These can make a big difference and help you feel much better.
Once you’re discharged, I’d like you to book a follow-up appointment here with us. We’ll go over what happened in hospital, check any new medications you’ve been started on, and talk through your diagnosis and how to manage things moving forward.
Management
Management
- Offer same-day admission via AMU or the Emergency Department due to previously low blood pressure and abnormal electrolyte levels.
- Ask if she has someone who can take her to hospital safely, such as her partner or a friend. Advise that she should not go alone, and she should let the person know what’s going on. If any problems arise on the way, they should stop and call 999 immediately.
- Inform her that in hospital, she will be given fluids through a drip to help stabilise her salt and potassium levels.
- Explain that further tests may be done in hospital to confirm if she has Addison’s disease. If confirmed, she will be started on lifelong steroid treatment to replace the hormones her body is not producing.
- Advise her to book a follow-up appointment after she is discharged from hospital to review what happened, go over any new medications that were started and discuss the diagnosis.
- Safety-net by advising that if she feels worse or has any new concerns while on her way to the hospital, she should contact the practice or call 111/999 depending on the severity.
Learning point from this station:
Adrenal insufficiency is a condition in which the adrenal glands fail to produce sufficient amounts of essential hormones, particularly cortisol, and in some cases aldosterone and adrenal androgens.
There are three types:
- Primary adrenal insufficiency (Addison’s disease): Caused by destruction or dysfunction of the adrenal cortex, leading to low levels of cortisol, aldosterone, and adrenal androgens (e.g. dehydroepiandrosterone).
Common causes include autoimmune disease (most common in developed countries) and tuberculosis (most common worldwide).
- Secondary adrenal insufficiency: Due to reduced ACTH(adrenocorticotropic hormone) production by the pituitary gland, leading to low cortisol and DHEA, but aldosterone is usually preserved and unaffected. Causes include pituitary tumours (e.g. pituitary adenomas), surgery to the pituitary, trauma etc.
- Tertiary adrenal insufficiency: Results from impaired corticotropin-releasing hormone (CRH) release from the hypothalamus, often due to long term steroid use (Usually greater than 3 weeks). Aldosterone is typically unaffected.Long-term steroid medication use can make the body stop producing its own steroids. If steroids are stopped suddenly, the hypothalamus won’t respond quickly enough and endogenous steroids (the natural steroids made by the body) are not produced in sufficient amounts. That’s why steroids must be reduced/tapered slowly to give the body time to recover.
If there is clinical suspicion of an impending adrenal crisis, emergency treatment should never be delayed for investigations, as untreated adrenal crisis can be rapidly life-threatening.
In adults, if adrenal insufficiency is suspected based on clinical features but there is no immediate danger, consider initial investigations such as: Serum cortisol (ideally taken between 8–9 a.m.), Urea and electrolytes (U+Es), Serum glucose, Calcium, Full blood count (FBC), Liver function tests (LFTs) and Thyroid function tests (TFTs)
In children, if adrenal insufficiency is suspected, investigations should be urgently arranged in secondary care. Depending on the clinical picture, this may require emergency admission via the children emergency department or children assessment unit. Use clinical judgment to determine the urgency.