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Solve the Medical Riddle: Her Broken Bone Isn’t Healing, Fourth Week

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

The first week of this riddle, the patient reported her symptoms to her PCP. The doctor proceeded with the examination using the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendation

The doctor ordered routine blood work and a bone density test. The PCP also referred Kathy to an endocrinologist. The second week, we learned the results of Kathy’s tests, and found out what happened when Kathy visited the endocrinologist. Last week, we let you know what some people had suggested as possible diagnoses. This week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Claudia K. correctly guessed the diagnosis! Kathy did indeed turn out to have the same condition President Kennedy kept secret – Addison’s disease. One symptom, though not all that common, can be bones that are brittle and slow to knit. That could be why Kathy’s foot fracture isn’t healing quickly. Also, President Kennedy did have severe back pain from fractured vertebra. We don’t know if there was a connection to his adrenal gland issue, but there might have been. Also, in Kathy’s case, early menopause probably contributed to her early onset osteoporosis. Thumbs up to Maureen G. for flagging that!

 

However, the results of Kathy’s blood work and her ACTH test are what clinched the diagnosis – in particular the high potassium levels that the endocrinologist called “urgently concerning”. In addition, Kathy’s high blood urea nitrogen (BUN) was from the volume of fluids caused by low adrenal function. Kathy also has an underactive thyroid and premature ovarian failure that pointed to an underlying autoimmune disease as the cause of her Addison’s.

 

Tuberculosis infection of the adrenals was a very common cause of Addison’s disease in days when TB was more prevalent, but now the cause is more often from an autoimmune disorder. Patients can present either acutely in crisis, such as when the massive stress of surgery or a severe infection challenges the adrenocortical (fight or flight system) that is already compromised or underactive from autoimmune disease. When the patient’s own adrenals can’t produce enough cortisol to handle the crisis, the person goes into shock and can die. Kathy, however, presented chronically – that is she showed evidence of an underactive adrenal system.

Kathy is being treated with lifelong prednisone, a corticosteroid, along with a mineral corticoid hormone. The brand name is Florinef. She will get booster doses of the medications if she ever has surgery or any stressful event, even a common cold or a tooth extraction.

She has been advised to increase her salt intake in hot weather to prevent low blood pressure. Beyond that, she now wears an emergency medical alert bracelet. Kathy was told to call her doctor immediately or go to urgent care of the emergency room if she gets any kind of illness. She has also learned how to give herself intramuscular (IM) injections of parenteral hydrocortisone (intravenous) if oral intake isn’t possible or when marked vomiting or diarrhea occurs.

Here’s what Kathy has to say:

“I actually count myself lucky that my foot fracture was so slow to heal. That’s what pushed me to see my doctor. He said catching my Addison’s early almost certainly prevented me from a ‘catastrophic collapse’ if I had ended up having a major stressful event at some point down the road. I can’t say I’m thrilled about being on medication for the rest of my life, but I’m grateful that there’s a way to keep my disease under control. Also, I still do have the year-round tanned look so I decided to play it up! I’ve started going gray, but I had my colorist make me blond again and I actually took make-up lessons on how to enhance my eyes without looking garish. People have started saying I look younger than ever! Then the other day out of the blue when I was in the grocery store, a cute guy walked by and said ‘Smokin’ tan, Lady!’ I have to admit that was fun. I also think it’s kind of cool that I have the same disease JFK had. I don’t like to talk about my health problems so I seldom mention that, but I did tell my book club when we read the book that disclosed JFK’s illness. Everybody was fascinated. I told them NOT to put my confession on Facebook, though! I like my privacy!”

Come back to ThirdAge.com next Thursday when we’ll introduce a new medical riddle!

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.