Case history
Case history #1
A 36-year-old woman presents with increasing fatigue especially in the afternoon, 7 kg weight loss, decreased appetite, diminished libido, and decreased axillary and pubic hair over a 10-month period. Her skin seems more tanned despite lack of sun exposure. She is craving salty food and feels dizzy when standing up suddenly. She has been dying her hair as she started having grey hair when she was 17 years old. Her mother has Hashimoto's thyroiditis and one of her sisters has type 1 diabetes. Her blood pressure is 102/66 mmHg with a heart rate of 86 beats/minute (supine) and 78/56 mmHg with a heart rate of 116 beats/minute (sitting). Hyperpigmentation is noted in the oral mucosa and also over a previous appendectomy scar.
Case history #2
A 63-year-old woman with severe degenerative osteoarthritis of the knees underwent total right knee replacement without immediate complications. She had a history of atrial fibrillation for several years and was on oral anticoagulant therapy and beta blockers. The oral anticoagulant therapy was discontinued before surgery and she was placed on intravenous heparin postoperatively. Two days after starting heparin therapy, she became fatigued and nauseated. Her supine blood pressure decreased from its preoperative value of 122/78 mmHg to 90/60 mmHg.
Other presentations
In adrenal crisis, patients are acutely unwell with dizziness, fatigue, hypotension, syncopal episodes, and loss of consciousness. Adrenal crisis is life-threatening and requires immediate treatment. Patients occasionally present exclusively with fatigue or unexplained low grade fever. Primary adrenal insufficiency may present in association with other autoimmune disorders.
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