Where you are:
You are the FY2 in GP,Who the patient is:
Samantha Lewis, a 27 year old woman has come for the review of her test
result
FBC - Normal
RBS- 7mmol/L
HbA1c - 5.1
UECr- Hyponatraemia, hyperkalaemia,
other parameters normalWhat you must do:
Talk to her, Discuss test results and address her concerns
PATIENT INFORMATION:
You went to the GP a week earlier because you have been feeling tired in the last 2-3 months. You
also feel more thirsty and urinating more frequently. You are losing weight as well and its been really
affecting your activities.
You are a type 1 diabetic since childhood and presently on lantus, novorapid and artovastatin.
You have no allergies.
You recently travelled to Turkey 
and began to notice some dark discolouration of your knuckles ,
neck and lips.
Your older sister has hypothyroidism and she’s presently doing okay.
Your diet is good but your cravings for salty diets has increased lately.
You also exercise. You neither take alcohol nor smoke cigarettes.
When ICEed, ask the doctor if this could be diabetes?"
Scenario B
The patient had the test done in a wellwoman clinic and she’s overweight.
EXAMINERS PROMPT:
Observations BP- 148/102 mmHg
GPE- hyperpigmentation of skin around the neck and knuckles
Neck- normal
Abdomen- normal
Urinalysis- glycosuria
QUESTIONS:
If the doctor tells you that you have addison’s disease, ask him what is it?
How did I get it?
Is this serious?
What will you be doing for me?
Can I drive myself to the hospital?
If the doctor mentions referring you to the ED, ask him, why can’t I go home?
APPROACH:
GRIPS
Paraphrase your entry
Doctor: I understand you had some tests done, has anyone discussed the results with you?
Patient: No
Doctor: I have your test results with me and I want to explain them to you shortly. But before we do
that I would like ask a few questions to get a better understanding of your situation and to make sure
we are both on the same page. Is that okay?
HISTORY
Then ask: Symptoms – Inx – Dx – Tx – Now.
Can you take me through what led you to see the doctor in the first place? (symptoms)
Do you know what tests were done and what we were looking for? (Inx)
What was done for you? (Tx)
Are you still having the symptoms? (Now)
DDx Tiredness
A- Anaemia
B- Bone (TB, multiple myeloma)
C- Cancer
D- Depression
E- Endocrine: DM, hypothyroidism, Addisons.
PMAFTOSA
Pychosocial (effects)
ICE
EXAMINATION 1) Obs 2) GPE including looking for pigmentation 3) Urine dipstick
EXPLAIN RESULTS / DIAGNOSIS
Thank you for answering my questions and for letting me examine you today. Looking at the results I
can see that some of the salt levels in your blood are abnormal. I am suspecting you could be
experiencing a condition known as Addison’s disease.
Offer explanation: Is that something you’ve heard of before? Would you like me to explain that
further?
It is a rare condition that affects the adrenal glands which sit on top of our kidneys. The adrenals
glands are responsible for producing the hormones cortisol and aldosterone.
What caused this?
The exact cause is not known but it could be autoimmune since you mentioned you have type 1
diabetes and your older sister has hypothyroidism. Am I making sense so far?
Is this serious?
Addison’s disease if left untreated can be potentially life-threatening. You can develop something
called an Addisonian crisis AKA adrenal crisis. I’m really glad you’ve come to see us and we’ll be
giving you the best possible treatment to minimise these kind of complications from happening. How
does this sound?
MANAGEMENT
Decision: I would advise an immediate transfer to A & E today, so that you can be assessed and the
abnormal salts in your blood can be corrected today. You would also get the chance to be reviewed
by the specialist (endocrinologist). How does that sound?
What specialist will do (AIT):
- Assess
- Inx: The specialist will check the level of some of your hormones (ACTH, cortisol and
aldosterone), TFTs and do an US scan of the tummy. They may also do a special test for
Addisons disease called a Synacthen test. - Tx if confirmed: They may give you some steroid medications to replace the low level of
cortisol and aldosterone that would need to be taken lifelong (hydrocortisone and
fludrocortisone)
Advice:
- Early recognition of Addisonian crisis
- If confirmed:
- Increase dose of steroids during illness, infection or surgery.
- Steroid emergency card
- Emergency steroid injection kit.
Can I drive myself to the A&E?
Unfortunately, it may not be safe to do so. As a matter of fact, you may have to inform the DVLA as
driving can put you in harm’s way?
Support groups
Scenario B
You’ll manage as above but you’ll still need to do some counselling on lifestyle modification for the
woman to lose weight.