Recurrent hypoglycemia (Addisons disease)

A 25 year old gentleman presents to the ED with fevers, abdominal pain and vomiting. The patients mother had mentioned that over the last 2 weeks he had been complaining of a few episodes of hypoglycemia at work. He has also been complaining of dizzy spells over the last 4 weeks as well. How would you approach this patient?

Answer

I would start off by taking a focused history on his gastrointestinal symptoms and ask for any history of contacts with anyone with similar symptoms. I would also explore the episodes of hypoglycemia that he had. I would also ask about the dizzy spells and whether there was evidence of other cardiovascular symptoms. I would also ask about his social history and family history. After this I would go ahead to do a focused A to E assessment.

• Airway: I would ensure the airway is patent and if necessary insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct I would be really worried and seek the help of the critical care team after my assessment if there was a problem with the airway assessment.
• Breathing: I would look at the observations specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has an increased work of breathing I’ll start the patient on supplemental oxygen therapy. I would also get a PEFR and an ABG done for this patient to see what the ph, Po2 , pco2 and hcO3 and lactate. I would be very concerned if the HcO3 and PH are very low. I would also keep an eye out on the electrolytes on the blood gas that was done. I would also arrange a portable CXR for the patient.
• Circulation: I would look at the observations specifically the BP, heart rate and CRT. If there is evidence of hypotension or tachycardia I would give a fluid challenge to the patient to see if there is an adequate response. And if the patient remains hypotension despite the first fluid challenge I will give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient. I will also request a lying and standing blood pressure to look into the orthostatic hypotension.
• Disability: I would check the patients blood glucose and capillary ketones, temperature and do a focused neurological assessment that includes GCS. Specifically if the GCS is less than 8 or if there is a focal neurological deficit I would be concerned and investigate this further.
• Exposure: I would examine the patients abdomen and look for evidence of an intra-abdominal pathology.

Question

He has a temperature of 38 degree Celsius, respiratory rate of 16/min and BP of 100/60. The VBG done by the ED sister shows a pH7.3, pCO2 4.7, HCO3 28, Na 115, K 5.3, Glu 2.0, Lactate 3.7. His ECG shows sinus tachycardia. What are the differentials here and how would you proceed?

Answer

My differentials here would be sepsis secondary to gastroenteritis, adrenal crisis, hypothyroidism.

Given the symptoms and initial tests there’s evidence of hyponatremia, hyperkalemia, hypotension and hypoglycemia, adrenal crisis would be my top differential here and the likely trigger would be the gastroenteritis in this case.

I would start off by giving broad spectrum antibiotics for the infection and IV fluids with fluid balance monitoring. I would also start him with IV hydrocortisone as well. I will ensure the patient has morning cortisol sent and a short synacthen test as well.

This patient would need daily bloods to ensure that the electrolyte imbalances are getting corrected and to ensure that the hyponatremia is not being corrected too quickly.