Case Study: I'm too tired to walk the dog...

A new case study in which the patient, T.K. a 51-year-old woman who has finally taken a staycation, doesn’t have enough energy to walk her dog. You’re the CSI – read through the findings, ask questions and make your guess!

Updated:  

This article was reviewed and fact-checked by our Editorial Team.
Case Study: I'm too tired to walk the dog...

Chief Complaint

"Over the last few months I've been increasingly exhausted. I thought maybe I just needed some time off, but now that I'm actually taking a break from work, I've been feeling worse than ever. This last week I haven't even been able to walk the dog.”

History of Present Illness

T.K. is a 51-year-old woman of mixed race who presents to her primary care provider with progressive fatigue, loss of appetite and mild nausea for the last 6 days. She has been at home for the last 5 days on leave from work but has been unable to take part in her usual activities including walking the dog and gardening. Her partner has insisted that she make an appointment with her primary care provider.

General Appearance

Looks fatigued: eyes and shoulders drooping, sighs deeply every few minutes, flat affect, moves slowly and with effort; pt appears female, skin is brown in color, appears stated age

Past Medical History

  • Broken clavicle from a fall from her bicycle, treated with surgery 10 years ago
  • Latent TB, Positive PPD 4 years ago, treatment with isoniazid (INH) for 9 months
  • High blood pressure, pre-diabetes and hypercholesterolemia for 2 years controlled with diet and exercise
  • Mild depression diagnosed 4 years ago, treated with Prozac and counseling

Family History

  • Mother had Ductal Carcinoma In Situ 15 years ago
  • Father had MI at age 65
  • One brother died from opioid overdose at age 21
  • One sister (age 45) with Graves disease

Social History

  • Born and raised in Asheville, NC
  • Works in an insurance office doing medical coding, previously had been an RN, but quit R/T latent TB
  • Partner teaches elementary school, no medical issues
  • Drinks 1-2 alcoholic beverages per week, non-smoker, occasional cannabis use, denies other drug use
  • Loves gardening and hiking with partner and dogs
  • Tries to walk daily and follows low carb, low cholesterol, low salt diet

Medications

  • Prozac 40 mg PO daily for mild depression
  • Acetaminophen 650 mg PO, every 4 hours PRN pain
  • Loratadine 10 mg PO daily for allergies
  • Benadryl 50 mg PO qhs PRN sleeplessness
  • Multivitamin, Centrum, PO daily

Allergies

NKA

Review of Systems (only abnormal systems are presented)

  • Weight loss of 10 pounds in last month
  • Salt cravings for several weeks until loss of appetite a week ago
  • Several bouts of dizziness, one fainting spell in last 6 months
  • Few aches and pains
  • Very dry skin, subnormal turgor, sporifice axillary hair, pigmented skin creases on palms of hand, elbows and backs of knees
  • Breasts have very dark areolae, hyperpigmentation prominent along brassiere lines
  • Moderately weak pedal pulses (1+)

Vital Signs

BP sitting, RA 96/72
HR 80/min
RR 12/min
T 98.7oF
HT 5 ft. 8 in
WT 170 lbs

What else do you want to know? Feel free to ask questions and make comments below.

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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Specializes in Urgent Care, Oncology.

I'd like to know the following:

Was a CMP, CBC, A1C, Cortisol, or ACTH drawn?

Was a ACTH stim test or hypoglycemia test done?

Any imaging?

I have a hunch, as I've seen a similar case before.

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Specializes in Education, Informatics, Patient Safety.
On 10/19/2019 at 11:01 AM, DowntheRiver said:

I'd like to know the following:

Was a CMP, CBC, A1C, Cortisol, or ACTH drawn?

Was a ACTH stim test or hypoglycemia test done?

Any imaging?

I have a hunch, as I've seen a similar case before.

I’ll be posting labs in a few days! Do you recall where you saw the other case? I’ve been working up several cases for my pathophysiology students- trying to be original and interesting!

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Specializes in Urgent Care, Oncology.
3 hours ago, SafetyNurse1968 said:

I’ll be posting labs in a few days! Do you recall where you saw the other case? I’ve been working up several cases for my pathophysiology students- trying to be original and interesting!

I've seen a patient with this issue before, not a case study.

Nonetheless, I think it's a great case study.

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Specializes in Education, Informatics, Patient Safety.
39 minutes ago, DowntheRiver said:

I've seen a patient with this issue before, not a case study.

Nonetheless, I think it's a great case study.

Oh that’s even better! Thank you so much!

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

Yep, also had a similar patient in the ER. I have made a post in the admin help desk. ?

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Specializes in Education, Informatics, Patient Safety.
Just now, Pixie.RN said:

Yep, also had a similar patient in the ER. I have made a post in the admin help desk. ?

Fantastic! So glad you read and commented.

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Specializes in Education, Informatics, Patient Safety.

Hey there fearless CSIs! I have more information for you!

Lab and imaging results just came in - check them out and be sure to enter your guess in the private Help Desk!

Laboratory Test Results

(Fasting, drawn at 9:00 am) [only abnormal or borderline labs are presented]:

Na 125 meq/L

K 5.3 meq/L

Cl 96 meq/L

BUN 20 mg/dL

Cr 1.2 mg/dL

Glucose 54 mg/dL

Cortisol 3 ug/dL

ACTH 902 pg/mL

UA Specific Gravity 1.016

Rapid ACTH Stim test:

Pre cosyntropin cortisol 2.0 ug/dL

30 min post cosyntropin cortisol 1.9 ug/dL

Imaging:

Abdominal CT scan revealed moderate bilateral atrophy of the adrenal glands

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Specializes in Vents, Telemetry, Home Care, Home infusion.

?

Labs confirmed my diagnosis hunch.

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Specializes in Education, Informatics, Patient Safety.
2 minutes ago, NRSKarenRN said:

?

Labs confirmed my diagnosis hunch.

Awesome! Thanks for playing!

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Specializes in Education, Informatics, Patient Safety.

Thanks so much for reading and commenting - here's the solution!

This patient has Addison’s disease caused by damage to the adrenal glands as evidenced by the abdominal CT. This primary adrenal insufficiency is confirmed by the Rapid ACTH stimulation test showing minimal elevation in cortisol with high levels of ACTH. The cortex of the adrenal gland has been damaged most likely by the latent tuberculosis the patient experienced. This has led to symptoms that relate to low levels of corticosteroids including glucocorticoids which support the body converting food to energy and help the body respond to stress; mineralcorticoids which maintain sodium and potassium balance and keep blood pressure normal and androgens which maintain secondary sexual characteristics like axillary hair.

Symptoms often develop so slowly they are ignored and include extreme fatigue, weight loss and decreased appetite, darkening of the skin, low blood pressure, salt craving, hypoglycemia, N/V/D, abdominal, joint or muscle pain, irritability, depression, body hair loss and sexual dysfunction in women. Untreated Addison’s disease can cause an Addisonian crisis as a result of stress, so people with addison’s (a lifelong disease since the adrenal glands don’t grow back) may carry a glucocorticoid injection kit with them and wear a medical alert bracelet. Patients are typically prescribed Cortef (hydrocortisone), prednisone or methylprednisone to replace cortisol. The hormones are given on a schedule to mimic normal 24 hour fluctuations of levels.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Here are the responses from members who came to the Admin Help Desk to submit their diagnoses for our 2nd Case Study Investigation (CSI): I’m too tired to walk the dog …

CONGRATULATIONS and THUMBS UP to those with the correct diagnosis!

What great diagnosticians!!

Thank you to all who participated. We hope you enjoyed this CSI.

Be watching for the next CSI installment coming very soon!

@Brenda Cruz Flores

Quote

? My guess is Addison’s Disease.

@spotangel

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? Addison's disease probably triggered by her TB.

@Anonymous865

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? Addison's disease

@bbmtnbb

Quote

? Addison's

@JKL33

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? Dx: Addison's disease. Pt has hx of TB and should be evaluated for active disease such as adrenal TB as a cause of Addison's/pt's symptoms.

Thank you.

@jrbl77

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? I think she has Addison's Disease. The fatigue and salt craving then weight loss keyed me in.

@AnxiousStudent1998

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? With the help of Google and Medscape my guess is Addison's Disease?

Copied and pasted messy notes from my thinking process:

more info:
-CBC (electrolytes and other fun things)
-date of last menstrual cycle (menopause? but amenorrhea is also part of Addison's disease)
-liver function (acetaminophen cause damage?)
-blood sugar

handy dandy Google told me we might need:
-short synacythen test
-blood electrolyte and plasma renin tests
-anti adrenal antibody test
-x-ray, Cat scan, or US of and to see size of adrenal glands to know damage

(but like, IDK which ones are most useful for Dx, available, and cost effective)

Things that line up with Addison's
-weakness
-progressive fatigue
-low appetite or unplanned weight loss
-dizziness or fainting due to low BP
-salt craving
-hyperpigmentation
-absence of axillary and pubic hair and decreased body hair in females
-few aches and pains
-weak periph pulses
-dry mucous membranes
-poor skin turgor
-mild nausea
-latent TB

not sure if explained by Addison's:
-flat affect (part of fatigue?)
-pre-diabetic Hx could affect the glucose measurement. hypoglycemia common w/addison's though

@Pixie.RN

Quote

? Addison's disease.

@DowntheRiver

Quote

? Addison's Disease, possibly related to TB/TB treatment

@rhythmqueen94

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? The latent TB, hyperpigmentation,salt cravings, light headedness,fainting and GI problems are all hallmark indicators of Addison's disease

@ebrine12

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? Addison's disease

@ednurse17

Quote

Is it hypothyroidism?

@Businessasset

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Hello! I am an aspiring nurse. I'm currently competing to get into a nursing program but have yet to be selected.

Now to the Case Study. My findings suggest that this pt might be experiencing Liver failure due to a combination of prolonged daily usage of acetaminophen and alcohol usage attribution.

@nrsang97

Quote

? The patient in the current article possibly has Addison's disease. Need ACTH, cortisol stim test, CMP, CBC.

@BlueShoes12

Quote

? I'm guessing Addison's disease based off the fatigue, weight loss, abnormal pigmentation, and hypotension.

Has a cortison, ACTH or A1C been drawn?

@mobaby

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Diabetes

@Ellekat

Quote

? Adrenal insufficiency (Addison's)

@JBudd

Quote

My first though was hyponatremia, followed closely by hypothyroidism.

@kidfloat

Quote

? Blood work? Cortisol?

Addisons?

@NRSKarenRN

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? Had patient in acute adrenal failure, late effect of TB on telemetry unit .... Addisons disease

Addisons disease signs include:

  • Extreme fatigue
  • Weight loss and decreased appetite
  • Darkening of skin (hyperpigmentation)
  • Low blood pressure, even fainting
  • Salt craving
  • Low blood sugar (hypoglycemia)
  • Nausea, diarrhea or vomiting (gastrointestinal symptoms)
  • Abdominal pain
  • Muscle or joint pains
  • Irritability
  • Depression or other behavioral symptoms

@DextersDisciple

Quote

? Addison’s disease

@jax225

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? My hunch is that the patient is suffering from Addison's disease.

Some signs and symptoms to support this include:

Presentation of hyponatremia, which seems to be confirmed by

  • low BP
  • fatigue
  • abnormal turgor
  • excessive salt cravings followed by loss of appetite, nausea

When lab results came back, this warranted further investigation into HPA axis issues due to:

  • Na 125 meq/L.
  • abnormal, alarmingly low rapid ACTH stim test
  • low cortisol levels
  • mild bilateral atrophy of adrenal glands

I'd recommend:

  • immediate electrolyte replenishment via IV so the pt does not drop below Na 125 meq/L and suffer severe health consequences (ex: coma)
  • oral corticosteroids followed by referral to endocrinology for long term treatment

@beachbabe86

Quote

? My guess is Addison's disease!

@KHVILLE

Quote

? Hi I wanted to submit my guess for the caste study that was posted. I think the patient is experiencing an Addisonian Crisis.

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