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
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.