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Case Study

Jack E. Robinson, a 21-year-old male, presents with symptoms suggestive of Addison's disease, including weakness, fatigue, knee pain, nausea, and gastrointestinal issues, alongside abnormally tanned skin. The treatment plan includes glucocorticoid and mineralocorticoid medications, lifestyle modifications, and a gradual exercise regimen. Following treatment, he developed Cushing's syndrome due to long-term glucocorticoid use, requiring a new treatment plan focused on reducing cortisol levels and addressing underlying causes.

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Mostafa Elashry
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5 views6 pages

Case Study

Jack E. Robinson, a 21-year-old male, presents with symptoms suggestive of Addison's disease, including weakness, fatigue, knee pain, nausea, and gastrointestinal issues, alongside abnormally tanned skin. The treatment plan includes glucocorticoid and mineralocorticoid medications, lifestyle modifications, and a gradual exercise regimen. Following treatment, he developed Cushing's syndrome due to long-term glucocorticoid use, requiring a new treatment plan focused on reducing cortisol levels and addressing underlying causes.

Uploaded by

Mostafa Elashry
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Case Study:

Subjective: Jack E. Robinson, a 21-year-old Caucasian male who lives


with his parents, reports to your clinic with a chief complaint of gradual
onset of weakness and fatigue, and pain in his knees. On a 0-10 scale, he
states that the pain in his knees is at a 3/10 at best and a 6/10 at its worst.
Jack works at United Parcel Service (UPS) at night while attending the
local community college during the day. His work duties require him to lift
boxes up to 60 lbs. by himself and he has been struggling to do so in
recent months, even becoming dizzy and nearly fainting a few times. He
has used almost all his sick days due to feeling nauseous and vomiting
while at work and occasionally before coming to work. He reported a
slight decrease in his weight and not being hungry nearly as often. He
used to stop by the 24-hour Subway for a sandwich every night after work,
but only goes one or two times per week in recent months. Now when he
goes the sandwiches taste bland and he has to use a lot of salt to make
them taste better. He states being nervous about eating certain foods
when he is hungry due to diarrhea which he has not figured out the cause
of. When asked, he states that his tanned skin from the summer has not
faded like it usually does even though it is well into the winter months
(January) and that he does not use a tanning bed. He states his parents
are worried because he is quick to become irritated with them and rarely
comes out of his room when at home.

Services: Jack has seen his primary care physician twice since the onset
of symptoms and last time was referred to PT with a prescription that said,
“evaluate and treat for weakness and fatigue”. He has received no other
care for his current condition.

Patient Goals: increase strength and stamina to return to peak


performance levels at work and so that workout regimen can resume.

Vitals signs:
HR: 78, BP:106/54, RR: 16

ROM:

All ROM within normal limits

Sensation/Reflexes:
All WNL

Observation:

Knee joint pain with palpation and passive motion


Abnormally tan skin.

Questions:

Based on assessment data and observation, what could be the patient


condition/diagnosis?

Addison's disease is a strong possibility. The following signs and


symptoms support this diagnosis:

Gradual onset of weakness and fatigue: A hallmark symptom of


Addison's disease due to adrenal insufficiency.
Pain in the knees: Could be associated with generalized muscle
weakness or other metabolic changes.

Nausea, vomiting, weight loss, and decreased appetite: Common


symptoms of adrenal insufficiency due to insufficient cortisol
production.

Dizziness and fainting: Often related to low blood pressure and


electrolyte imbalances seen in Addison's disease.

Skin changes: Abnormally tan skin (hyperpigmentation), especially in


areas exposed to friction (such as elbows, knees, knuckles), is a classic
sign of Addison's disease due to increased ACTH (adrenocorticotropic
hormone) levels stimulating melanocytes.

Gastrointestinal symptoms: Diarrhea could be related to electrolyte


imbalances, especially low sodium levels, which often occur in
Addison’s disease.

Irritability and withdrawal: Psychological symptoms like irritability and


withdrawal are commonly associated with Addison's disease due to the
lack of cortisol's role in stress response and mood regulation.

Draw a map with the treatment plan of the Addison's disease including
exercises and medications

After a while from the treatment, Mr. Jack, developed side effect from
long term glucocorticoid replacement which is Cushing syndrome.
Draw a map with the treatment plan of the Cushing syndrome including
medications for each underlying cause

Please note: Use the Lehne pharmacology book to guide drawing your two
maps

Treatment Plan for Addison's Disease:

. Medications:
Hydrocortisone (Cortisol replacement):

Dose: 15-25 mg/day (divided into 2-3 doses per day, with higher doses in the
morning and lower doses in the afternoon).

Cortisol is needed for maintaining blood pressure, energy, and stress


responses.

Fludrocortisone (Mineralocorticoid replacement):

Dose: 0.05-0.2 mg/day.

Fludrocortisone helps with salt and water retention to address the


hyponatremia and low blood pressure associated with Addison's disease.

DHEA (Dehydroepiandrosterone) (optional):

Dose: 5-25 mg/day.

For patients with diminished androgen production who experience symptoms


like fatigue, mood changes, and low libido.

2. Lifestyle Modifications:

Increased salt intake: Patients may require more salt in their diet, especially
during hot weather or periods of stress.

Stress management: Patients should increase their glucocorticoid dose during


periods of physical or emotional stress (e.g., infections, surgeries).

Hydration: Adequate fluid intake is essential, especially during warm weather,


to prevent dehydration and support blood pressure regulation.

3. Exercise:

Low-impact activities: Initially, Jack should focus on light exercises such as


walking, swimming, or cycling to improve endurance without overexertion.

Strength-building: Gradually incorporate resistance training (e.g., bodyweight


exercises, light dumbbells) to improve muscle strength and stamina.

Treatment Map for Cushing's Syndrome (Due to Long-term Glucocorticoid


Replacement):
Long-term use of glucocorticoids (like hydrocortisone) can lead to Cushing’s
syndrome, which occurs due to excess cortisol levels. The treatment plan for
Cushing’s syndrome is to address the underlying cause (e.g., reducing
glucocorticoid therapy or managing adrenal or pituitary tumors).

1. Medications for Cushing’s Syndrome:

Ketoconazole:

Dose: 200-400 mg/day.

An antifungal agent that also inhibits cortisol synthesis in the adrenal glands.
It’s used to reduce excess cortisol levels.

Metyrapone:

Dose: 250-750 mg/day (adjusted as needed).

Inhibits 11-beta-hydroxylase, an enzyme involved in cortisol production, to


help reduce cortisol synthesis.

Pasireotide (for pituitary tumors):

Dose: 0.6-1.2 mg subcutaneously every 24 hours.

A somatostatin analog that inhibits ACTH secretion from the pituitary gland,
helping reduce cortisol levels in patients with pituitary adenomas.

Mitotane:

Dose: 2-6 grams/day (titrated according to response).

This drug inhibits cortisol production by the adrenal glands and is particularly
useful for patients with adrenal tumors.

2. Surgical Treatment:

Transsphenoidal surgery (for pituitary tumors): If Cushing’s syndrome is


caused by a pituitary adenoma, surgical removal of the tumor may be
necessary.

Adrenalectomy: In cases of adrenal tumors or hyperplasia, removal of the


adrenal glands may be indicated.
3. Lifestyle Modifications:

Weight management: Cushing’s syndrome often leads to significant weight


gain, particularly in the abdominal area. A balanced diet with a focus on
calorie control, along with regular physical activity, can help manage weight.

Bone health: Cushing’s syndrome increases the risk of osteoporosis, so


ensuring adequate calcium and vitamin D intake and weight-bearing exercises
are essential.

4. Exercise:

Low-impact aerobic exercises: Focus on cardiovascular health through


activities like walking, cycling, and swimming to help manage weight and
improve heart health.

Strength training: Low resistance weight training exercises to help combat


muscle wasting, which is common in Cushing’s syndrome.

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