Trina Pullman is a 24-year old female with a history of hypothyroidism, with a 3-month history of persistent vomiting, followed by the gastroenterology service, thought to have gastritis based on the upper endoscopy report. She continued to have vomiting and weight loss, presented to the emergency department, found to be hypotensive, tachycardic and thin. Her serum labs demonstrated hyponatremia, normal potassium levels, and a random cortisol level that was very low. Thyroid stimulating hormone was normal. CBC was unremarkable, UA normal, negative pregnancy test. Serum glucose, liver function tests and renal function were normal. She was thought to have Addison’s disease, with a plan to admit to the hospital for further workup and treatment. You are the hospitalist AGACNP admitting the patient. What one medication would you initiate on this admission to treat the Addison’s disease?
Past Medical, Surgical, Social, and Family History
- Hypothyroid
- Gastritis
- Social History
- Smoker 2-3 cigarettes socially on weekends
- Recreational drug use-none
- ETOH-none
- Single, no children
- Employed as hairdresser
Medications
- Protonix 40mg po daily
- Levothyroxine 100 mcg po daily
Allergies
- none
Physical Exam
- Vitals: Pulse 104; Resp 18; BP 96/50; SpO2 98%; Temp 37 °C (98.6 °F); Wt. 65kg; Ht. 5’6″.
- Constitutional: Alert, no acute distress. Thin.
- HEENT: Head is normocephalic and atraumatic. Eyes without icterus or injection. Mucous membranes pink and dry. Neck is supple, nontender without adenopathy. No JVD. No meningismus.
- Resp: Lungs clear to auscultation bilaterally without wheezes, rales or rhonchi. No increased work of breathing.
- Cardiovasc: S1S2 without murmur, rub or gallop. Regular rate and regular rhythm. Pedal pulses 2+ and equal. No edema.
- Abd/GI: Soft, non-tender, nondistended. No masses.
- Skin: Pink, warm, dry. No rashes or bruising.
- Ext: Movement all extremities without limitation.
- Back: Normal inspection. Nontender.
- Psych: Affect normal. Appropriate attention, cooperation.
- Neuro: Alert and oriented x 4. No focal motor or sensory deficits.
Complete the Following Questions for Each Category
Addison’s Disease Medication
- Write out the order including the pharmaceutical agent, dose, route and when it should be given.
- Justify the rationale on why this medication was selected in this particular situation.
- Discuss the class/schedule of medication chosen.
- Discuss the pharmacodynamic action of the med.
Side Effects/Adverse Reactions/Interactions
- Discuss the potential side effects and/or adverse drug reactions for the first line treatment in THIS patient (not generically).
- Discuss reasons/indications why not to give this medication in THIS patient.
- Discuss the side effects that THIS patient might encounter after receiving this medication, as well as what to do should they occur.
- Discuss any potential drug interactions for the initial medication option for THIS patient and what the management should be if there was a concern about a drug interaction. (Note: This answer may be none.)
Cost & Efficacy
- Document the cost of this initial medication with reference for where that information was obtained.
- Discuss how the cost compares to other options available for this patient.
- Discuss whether the cost of this medication chosen is the best option based on cost, effectiveness and indication for this particular patient.
- Discuss any diagnostics tests or other information that might need to be obtained to show that medication is efficacious
Special Considerations
- Discuss how would the treatment chosen should change IF the patient was pregnant.
- Discuss specifically the pregnancy category for this medication choice.
- Discuss specific approaches to this medication or alternatives with a pregnant patient.
- Discuss how the treatment chosen should change IF the patient was a 75-year-old male.
