HISTORY. Determine if the patient has a history of recent infection, steroid use, or adrenal or pituitary surgery. Establish a history of poor tolerance for stress, weakness, fatigue, and activity intolerance. Ask if the patient has experienced anorexia, nausea, vomiting, or diarrhea as a result of altered metabolism. Elicit a history of craving for salt or intolerance to cold. Determine presence of altered menses in females and impotence in males.

PHYSICAL EXAMINATION. Assess the patient for signs of dehydration such as tachycardia, altered level of consciousness, dry skin with poor turgor, dry mucous membranes, weight loss, and weak peripheral pulses. Check for postural hypotension—that is, a drop in systolic blood pressure greater than 15 mm Hg when the patient is moved from a lying to a sitting or standing position.

Inspect the skin for pigmentation changes caused by an altered regulation of melanin, noting if surgical scars, skin folds, and genitalia show a characteristic bronze color. Inspect the patient's gums and oral mucous membranes to see if they are bluish-black. Take the patient's temperature to see if it is subnormal. Note any loss of axillary and pubic hair that could be caused by decreased androgen levels.

PSYCHOSOCIAL. Because an acute adrenal crisis may be precipitated by emotional stress, periodic psychosocial assessments are necessary for patients with adrenal insufficiency. Patients with an adrenal insufficiency frequently complain of weakness and fatigue, which are also characteristic of an emotional problem. However, weakness and fatigue of an emotional origin seem to have a pattern of being worse in the morning and lessening throughout the day, while the weakness and fatigue of adrenal insufficiency seem to be precipitated by activity and lessen with

46 Adrenal Insufficiency (Addison's Disease)

rest. Patients with adrenal insufficiency may show signs of depression and irritability from decreased cortisol levels.

Diagnostic Highlights

General Comments: To determine if a Cortisol deficit exists, a plasma Cortisol level is

drawn in the morning; less than 10 mcg/dL suggests adrenal insufficiency; further test

ing may be needed to determine if the adrenal glands have a primary deficiency or if

the pituitary cannot produce enough ACTH (secondary adrenal failure).

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