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Diagnostic Analysis

With the low cortisol level, the diagnosis of Addison disease was made. Her ACTH was high, indicating secondary adrenal failure. ACTH has actions comparable to melanocytic-stimulating hormone thus causing hyperpigmentation, and elevated levels of ACTH caused this woman to be very darkly tanned. No pituitary tumor was found indicating that this was primary adrenal failure. Her elevated ANA and hydroxylase antibodies indicated that she had an autoimmune cause of her Addison’s disease. The small or absent adrenal glands noted on CT scan corroborated autoimmune destruction of her adrenal glands.
Although one of her main presenting symptoms was upper GI dysfunction, no pathology, such as peptic disease, was found. Her reduced gastric transit was caused by her Addison disease.
Critical Thinking Questions
1. Of all the tests this young woman had, which single test would be easiest, most diagnostic, and would have explained her entire symptom complex? 

2. What are some of the other adrenal function tests that could have been performed to assist in the diagnosis of this woman’s adrenal failure? 

3. What is the difference between primary and secondary Addison disease, and how can the two be separated? 

4. Why was this woman’s sodium low and her potassium elevated? 

Pneumonia Case Studies
A 73-year-old white male has been experiencing shortness of breath and left-sided chest pain for the last 24 hours. More recently, he has noted shaking chills and a fever. About 3 days before, he had been drinking alcohol excessively and passed out. When he awoke, he noted vomitus on his shirt. He does have a history of hypertension and coronary artery disease.
His physical examination indicated that he was tachypneic and had a fever. His heart rate was 110 per minute. His chest examination demonstrated rhonchi in the lower lateral left chest.

Diagnostic Analysis
The cause of shortness of breath in this older adult male could be myocardial ischemia, congestive heart failure, pneumonia, or pulmonary embolism. His history of having vomited while unconscious raises the suspicion of aspiration pneumonia. His high WBC and the fever are more compatible with infection. His normal BNP excludes the possibility of congestive heart failure. His chest X-ray demonstrates classic aspiration pneumonia.
Critical Thinking Questions
1. What are some other tests that could help delineate the cause of shortness of breath? 

2. To what antibiotic is Klebsiella commonly sensitive? 

3. Should antibiotics be provided empirically upon the initial visit or should antibiotics be withheld until culture and sensitivity reports are available? 

4. What are the potential social problems associated with this man’s care and future discharge? 

5. What do the abnormal liver enzymes tell you about his alcohol use?