Addison's Disease
Red Flags — the crisis and the missed diagnosis
| Red flag | Why dangerous | Action |
|---|---|---|
| Adrenal crisis — hypotension/shock, vomiting, abdominal pain, confusion, profound weakness | Life-threatening hypovolaemic/distributive shock; rapidly fatal if untreated. Often precipitated by infection, illness, surgery or missed steroids. | Immediate IV/IM hydrocortisone (100mg) + IV fluids + treat hypoglycaemia; 999/admit; do NOT wait for test results |
| Postural hypotension + nausea in the at-risk patient | Signals decompensation/impending crisis even before full shock. | Urgent same-day assessment; do not send home to await an outpatient test |
| Unexplained hyponatraemia / hyperkalaemia with fatigue & weight loss | Classic biochemistry of adrenal insufficiency; easy to overlook on a routine U&E. | Urgent cortisol/ACTH; senior/endocrine advice; consider admission |
| Hypoglycaemia | Cortisol deficiency impairs glucose counter-regulation, especially in children/fasting. | Treat hypoglycaemia; consider adrenal insufficiency |
| Known patient who has stopped / can't absorb steroids (vomiting) | Abrupt steroid cessation or vomiting precipitates crisis. | Emergency hydrocortisone injection; sick-day rules; admit if vomiting |
| Repeated "stress/depression" labels with weight loss + pigmentation | Anchoring leads to dangerously delayed diagnosis until crisis. | Step back; test for Addison's (cortisol, U&E); refer endocrinology |
🙇 Being believed
Validate that the symptoms are real and not yet explained; avoid re-anchoring on stress.
"I don't think this is just stress, and I'm sorry if it's felt like you weren't being heard. Your symptoms are real, and I want to test for a specific cause."⚖️ Serious but treatable
Convey the seriousness honestly while giving hope — replacement treatment restores normal life.
"If it's what I suspect, it's a serious condition because the body isn't making an essential hormone — but it's very treatable: people live full, normal lives by replacing that hormone."🆘 Why today matters
Explain why the current nausea and low BP may need same-day assessment.
"Because you're nauseated and your blood pressure drops when you stand, I don't want to just wait for an outpatient test — I'd like you assessed urgently today to be safe."🧬 The autoimmune link
Connect her vitiligo and family thyroid disease to the picture.
"Your vitiligo and your mum's thyroid problem matter here — these conditions run together, which is part of why I'm thinking along these lines."NICE NG243 (2024) asks clinicians to think about adrenal insufficiency when a patient has symptoms such as fatigue, weight loss, postural dizziness, nausea or abdominal pain, salt craving or hyperpigmentation, or has unexplained hyponatraemia, recurrent hypoglycaemia, or a relevant history of glucocorticoid exposure. The trap Hannah has fallen into is that these symptoms are non-specific and easy to put down to psychological or functional causes. Every time a patient comes back with the same unexplained symptoms, it is a chance to reconsider the diagnosis. Three visits for fatigue plus weight loss is a pattern, not a coincidence.
- Re-anchoring on stress/depression and missing the cluster
- Not eliciting pigmentation / salt craving / postural symptoms
- Not recognising impending crisis in a nauseated, hypotensive patient
- Ignoring the autoimmune background
Now / 999
Treat before testing- Adrenal crisisShock, vomiting, confusion → IV/IM hydrocortisone + fluids + glucose; 999/admit
- Impending crisisPostural hypotension + nausea + intercurrent stress → urgent same-day assessment
- Severe hyponatraemia / hyperkalaemia / hypoglycaemiaUrgent admission
Days
Endocrine- Symptomatic suspected Addison'sUrgent endocrinology; cortisol/ACTH + Synacthen
- Low 9am cortisolExpedite confirmatory testing
- Known patient, intercurrent illnessSick-day rules; review
Work-up
Confirm & screen- Stable suspicious picture9am cortisol, U&E, glucose; arrange Synacthen
- Autoimmune screenTFTs, B12, coeliac, glucose
- Established, stable Addison'sAnnual review; education
- Sending a decompensating patient home to await an outpatient test
- Waiting for cortisol results before treating a crisis
- Not checking postural BP; not looking for pigmentation
- Missing signs of decompensation
| 8–9am serum cortisol | NG243 interpretation and action |
|---|---|
| <150 nmol/L | Adrenal insufficiency is likely. Start management and refer to endocrinology (same day or urgently, depending on how unwell the patient is) for confirmation and treatment. |
| 151–200 nmol/L | Refer to endocrinology or arrange a short Synacthen test. |
| 201–300 nmol/L | Uncertain range. Consider repeating the 8–9am cortisol; if it stays in this range, refer to endocrinology or arrange a short Synacthen test, especially if the patient has symptoms and hyponatraemia. |
| >300 nmol/L | Adrenal insufficiency is very unlikely. Look for another cause of the symptoms, but reconsider if the clinical picture changes. |
These NG243 cutoffs apply to modern cortisol immunoassays. If your laboratory uses a different assay, follow local guidance. Oral oestrogen raises cortisol-binding globulin, and recent exogenous glucocorticoids (including inhaled, topical and injected steroids) suppress the axis or cross-react with the assay (prednisolone does; dexamethasone does not). Tell the laboratory about both on the request form.
- Timing matters. Cortisol peaks early in the morning, and a sample taken in the afternoon is hard to interpret. Book a slot between 8 and 9am. For a shift worker, discuss timing with the laboratory.
- Pair it with ACTH if your laboratory accepts it (the sample usually has to reach the lab quickly, on ice or as an EDTA sample per local rules). A high ACTH with a low cortisol shows the problem is in the adrenal gland.
- The short Synacthen test (tetracosactide, with cortisol measured at baseline and 30 minutes) is usually arranged by endocrinology or a hospital day unit, not in general practice. The pass threshold depends on the laboratory and assay.
- Do not wait for results when the patient is unwell. If crisis is suspected, take a sample only if it causes no delay, then give hydrocortisone 100 mg IM/IV. Endocrinology can still confirm the diagnosis later, once the patient is stable.
- Renin and aldosterone: a high renin with a low or inappropriately normal aldosterone confirms mineralocorticoid deficiency in primary disease. These are usually specialist-requested and guide the fludrocortisone dose.
- A normal U&E does not exclude it. Hyperkalaemia is absent in a significant minority of cases, and secondary adrenal insufficiency causes hyponatraemia without hyperkalaemia.
- Delaying crisis treatment for test results
- Not knowing the 9am cortisol → Synacthen pathway or the role of ACTH
🚩 The discipline — name it before the crisis
The whole value of recognising Addison's is making the diagnosis from chronic symptoms, before the patient decompensates. For Hannah the formulation is primary (autoimmune) adrenal insufficiency — fatigue, weight loss, salt craving, pigmentation, postural hypotension, an autoimmune background, and likely low Na/high K — now showing early decompensation. That demands urgent assessment, treatment that does not wait for confirmation if she crises, lifelong replacement, and meticulous safety-netting (sick-day rules, emergency kit, alert card).
- Not distinguishing primary from secondary
- Accepting the depression label without excluding Addison's
- Routine referral for a decompensating patient
- Starting lifelong replacement without specialist confirmation in a stable case
Validate — name the expectation and the history of being dismissed
Hannah has two expectations that pull against each other. She dreads another "it's burnout" and wants to be believed. But she may also expect, and quietly prefer, to go home today with a blood form, because hospital feels like an overreaction and she has work and home to sort out. Naming both stops the plan being heard as either another dismissal or an alarming overreaction.
"You've come back three times, and I suspect you were half-expecting to be told it's stress again. I don't think it is. I also wonder whether part of you hoped to go home today with a blood test and see what it shows. Is that fair?"Explain — why today is different from the last three visits
The reasoning should be transparent. The pattern (weight loss, salt craving, darkening skin, dizziness on standing, an autoimmune background) points to the adrenal glands. Her nausea and postural drop today suggest the body is struggling to cope. If this is adrenal insufficiency, the treatment is a steroid injection and a drip, and it is given before the confirmatory test because waiting is what is dangerous. That is why a routine outpatient blood test is not safe enough today.
"Everything you've told me fits a problem where the adrenal glands, two small glands above the kidneys, stop making cortisol, a hormone the body can't do without. Today you're sick and your blood pressure drops when you stand, which suggests your body is running out of reserve. If I'm right, the treatment works quickly, but it needs to start today rather than after a test next week."Negotiate — a concrete plan, with her practical worries addressed
She leaves with a clear plan: same-day assessment by the acute medical team (or 999 if she deteriorates in the surgery), bloods taken now if that causes no delay, a phone call to the medical registrar, a written summary for the receiving team, and help with whatever is stopping her going (work, children, transport). If crisis features appear while she is in the surgery, parenteral hydrocortisone is given there and then.
"Here's what I'd like to do. I'll take some blood now and phone the hospital medical team so they're expecting you this afternoon. They can start treatment and do the confirmatory test. What would make it hard for you to go today? Let's sort that out together."A healthy adrenal gland raises cortisol output several-fold during fever, injury or surgery. A patient on fixed replacement cannot do that, so the extra cortisol has to be taken as extra tablets or an injection. Without it, vascular tone, glucose and sodium balance fail and the patient goes into shock.
Rule 1: for significant illness, fever or infection needing antibiotics, increase the oral glucocorticoid: an extra 20 mg hydrocortisone at once, then at least 40 mg hydrocortisone a day in 2–4 divided doses (or at least 10 mg prednisolone a day in 1–2 doses), or the individual steroid plan, until recovered (NICE NG243; site protocol). Rule 2: vomiting, diarrhoea or unable to keep tablets down means IM hydrocortisone from the kit plus urgent help. The Society for Endocrinology leaflet (2025) adds that mild illness without fever needs no change. Vomiting within 30 minutes of a dose means repeating it at double the original dose once vomiting settles; vomiting again within 30 minutes means IM hydrocortisone from the kit and the emergency department (site protocol). Rehearse the rules at every contact and use teach-back.
The patient who most needs the injection may be too confused or weak to give it. IM hydrocortisone works within minutes to hours and bridges the gap until paramedics arrive. There is no meaningful overdose risk from a single emergency dose, so doubt should never stop anyone giving it.
Prescribe two or three emergency kits (NG243), each with hydrocortisone sodium succinate 100 mg vials, water for injection, needles and syringes (or a local equivalent kit). Train Hannah and a partner, friend or colleague, using the Addison's Disease Self-Help Group or Society for Endocrinology videos, the practice nurse, or the endocrine specialist nurse. Put expiry dates on recall. After injecting, always call 999.
Adrenal crisis looks like sepsis, gastroenteritis or an acute abdomen. Without a prompt, a paramedic or emergency department team may give fluids and antibiotics but not hydrocortisone. The red NHS Steroid Emergency Card, introduced by National Patient Safety Alert NatPSA/2020/005/NHSPS in August 2020, tells any clinician what to give and when.
Issue the card, and suggest a photo of it on her phone plus a medical-alert bracelet or necklace. Code adrenal insufficiency and steroid dependence on the GP record, and consider an alert on the Summary Care Record or local shared record. Ask the ambulance service about registering her where a local scheme exists.
In primary disease, aldosterone deficiency causes renal sodium loss, volume depletion and postural hypotension. Salt craving is the body's attempt to compensate. Fludrocortisone replaces aldosterone, but heat, heavy sweating and endurance exercise increase losses further.
Do not advise the usual "low-salt diet" health message. Hannah can salt food to taste. In hot weather or on holiday in hot countries she should drink more and add salt. The specialist may adjust the fludrocortisone dose. Persistent salt craving or a postural drop on treatment suggests under-replacement, so check BP and U&E and discuss renin with endocrinology.
Travel concentrates the risk factors: gastroenteritis, heat, time-zone shifts that disrupt dose timing, lost luggage, and limited access to parenteral hydrocortisone abroad.
Carry at least double the supply of tablets, split between bags, with the injection kit and a translated or English doctor's letter in hand luggage. Take the card and alert ID. Get travel insurance that declares the condition. Take oral rehydration sachets. Keep dosing by waking time across time zones, and ask the specialist team about long-haul flights. Know how to reach emergency care at the destination.
Infection, especially gastroenteritis and respiratory infection, is the commonest trigger for crisis. Replacement-dose hydrocortisone is not immunosuppressive, but people with adrenal insufficiency are more vulnerable to the physiological stress of infection.
Offer the seasonal vaccines she is eligible for under the current UKHSA Green Book and local call-recall; check eligibility each season. Infections should be assessed early rather than "sat out". Apply the sick-day rules at the first fever, not the third day. Live vaccines are not contraindicated by physiological replacement doses (UKHSA Green Book, chapter 6).
Anaesthesia, surgery and bowel preparation (fluid loss) are major physiological stressors. The patient cannot mount a stress response and may be nil by mouth.
The 2020 guideline from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology (Woodcock et al., Anaesthesia) recommends hydrocortisone 100 mg IV at induction then 200 mg/24 h by infusion for major surgery, with procedure-specific cover for lesser procedures. The GP's role is to make sure every surgeon, anaesthetist, dentist and endoscopy unit knows in advance (the card, the referral letter), so cover is planned rather than improvised. Colonoscopy bowel preparation and significant dental work under local anaesthetic also need a plan agreed with the team or endocrinology.
Quality of life is reduced in a proportion of treated patients, with residual fatigue, anxiety about crisis and "not feeling normal". Peer support normalises the experience and spreads practical know-how, such as how to explain the condition at work and how to travel.
Signpost the Addison's Disease Self-Help Group (ADSHG), and the Pituitary Foundation for secondary causes. Offer the Society for Endocrinology patient leaflets. Screen mood with PHQ-9 at review and offer NHS Talking Therapies if needed. Hannah's earlier low mood may lift with replacement, but check that it has.
Hydrocortisone 100 mg IM or IV immediately (adults and children aged 6+)
- Children: 25 mg under 1 year, 50 mg aged 1–5 years, 100 mg aged 6 and over (BSPED age-based doses adopted by NG243)
- Call 999. In hospital: IV 0.9% saline (site protocol: 1 L over 30 minutes in adults), check glucose and treat hypoglycaemia, find and treat the trigger
- Take a random cortisol ± ACTH first only if it does not delay treatment
- No meaningful overdose risk: doubt is not a reason to withhold it
Hydrocortisone, usually 15–25 mg/day in adults, in 2–3 divided doses (NG243)
- Largest dose on waking to mimic the circadian peak, e.g. 10 mg on waking, 5 mg at midday, 5 mg mid-afternoon (the site protocol's example)
- Last dose not too late in the evening, to avoid insomnia
- Titrate to symptoms, weight, BP and signs of over-replacement, never to a single random cortisol
- Alternatives (specialist choice): prednisolone once daily; modified-release hydrocortisone (Plenadren, Efmody). If on modified-release, the patient also needs immediate-release hydrocortisone for sick days (NG243)
Fludrocortisone once daily, dose per SPC and specialist
- Needed in primary adrenal insufficiency (Addison's). Not usually needed in secondary disease, because the renin–angiotensin–aldosterone system still works
- Titrated to postural BP, sodium and potassium, and plasma renin (specialist), plus symptoms such as salt craving
- Too much causes oedema, hypertension and hypokalaemia. Too little causes postural dizziness, salt craving and a high renin
- Do not double fludrocortisone on sick days. Only the glucocorticoid is increased
"These tablets replace a hormone your body can no longer make. You take them every day for life, even when you feel well. When you're ill with a fever you take extra. If you vomit and can't keep them down, use the injection and ring 999. Never let yourself run out. Order your next prescription as soon as you open your last box."
SCA phrase: "This isn't like other tablets you can stop if you feel better. Your body depends on it the way it depends on food and water, so it's for life, and you'll need more on days you're ill."
"This tablet replaces the salt-keeping hormone. It's why you've been craving salt and feeling dizzy when you stand. Take it every morning. If your ankles swell or you get headaches, let us know, because the dose may need adjusting."
SCA phrase: "There are two hormones missing, so there are two tablets. One replaces cortisol for energy and coping with illness. The other replaces the hormone that keeps salt and blood pressure steady."
"This is your safety net. If you're vomiting and can't keep your tablets down, or you're feeling faint and confused, you or someone with you injects this into the thigh muscle, then rings 999 and says 'adrenal insufficiency, emergency steroid given'. You can't overdose on it, so if in doubt, inject."
SCA phrase: "Who at home could learn to give this? I'd like them trained too, because if you're very unwell you might not be able to do it yourself."
"Because you've been on steroids for a while, your own adrenal glands have gone to sleep. That's why you mustn't stop suddenly, and why you need extra steroid, or the injection, if you're very unwell. Carry this red card so any doctor treating you knows."
SCA phrase: "Your inhaler and steroid creams count too. High doses over a long time can have the same effect on your adrenal glands as tablets."
"Your once-daily tablet releases slowly, so it can't be doubled quickly enough when you're ill. On sick days you switch to the ordinary hydrocortisone tablets as your specialist has written down."
SCA point: a GP who knows that modified-release preparations need a separate immediate-release sick-day supply shows safe shared-care prescribing.
Work
Months of untreated fatigue may already have hurt her performance or attendance. After starting replacement, recovery usually takes weeks, and some people have residual fatigue. Addison's is a long-term condition and is likely to count as a disability under the Equality Act 2010, which entitles her to reasonable adjustments: flexibility for dose timing, sick-day absence without penalty, a kit kept at work and a trained colleague.
Fit note for the recovery period if needed. Occupational health referral for shift work, heat or physically demanding roles.
"Would it help to talk through what you tell work? Many people keep a spare injection kit at work and show a colleague how to use it. Would anyone there be willing?"Driving and DVLA
Addison's disease itself is not usually a condition that car or motorcycle (Group 1) licence holders must report to DVLA. Bus, coach and lorry (Group 2) licence holders must tell DVLA (GOV.UK / NHS inform guidance). The practical risks are driving while in impending crisis (dizziness, confusion) or hypoglycaemia. If the cause is secondary (a pituitary tumour), DVLA rules for the tumour and any visual field loss apply separately.
"You don't need to tell DVLA for an ordinary car licence. But don't drive if you feel faint, confused or are vomiting, and keep your card and kit in the car too."Family and Carers
Family members become part of the safety system. They need to recognise crisis and to give the injection. That can feel like a heavy responsibility, especially for a partner, older child or parent. Her mother's thyroid disease also raises the question of family members' own autoimmune risk.
"Could whoever you live with come to the nurse appointment? It's much less frightening once you've practised the injection together, and it means they know what to do."Fertility, Pregnancy and Contraception
Women with Addison's can have healthy pregnancies with joint obstetric–endocrine care. Replacement may need adjusting in later pregnancy, labour needs stress-dose cover, and hyperemesis is a crisis risk (it is sick-day rule 2). Pre-conception advice matters. Oral oestrogen affects total cortisol measurements, which matters for interpretation rather than safety.
"If you're thinking about pregnancy at any point, tell us early. It's very possible, and the specialist team will plan the doses with you."Mood, Anger and Trust
Anger at the diagnostic delay is common and legitimate. Some patients also have health anxiety about crisis and hyper-vigilance with every illness. Low mood may be partly due to the cortisol deficiency and improve with replacement, but it should be rechecked rather than assumed. An honest acknowledgement of the delay, rather than defensiveness, rebuilds trust. Significant events and learning should be handled through practice processes.
"I'm sorry it's taken this long. It's understandable if you feel angry. I'd like to make sure your care from here is joined up, and you can always come back to talk about how you're coping."Identity and an Invisible Condition
Addison's is invisible: patients look well until they are very unwell. Carrying a red card, wearing an alert bracelet and explaining the condition to friends, schools, gyms or new clinicians can feel stigmatising at first. Peer support (ADSHG) helps people make the condition part of normal life rather than a threat hanging over it.
"Lots of people with Addison's run marathons, travel the world and have families. The card and the kit are what let you do all that safely."Today — Same-Day Assessment
Bloods (U&E, glucose, cortisol ± ACTH) only if they cause no delay. Phone the acute medical registrar. Written handover including the suspicion of adrenal insufficiency. If crisis features appear in the surgery: hydrocortisone 100 mg IM, then 999. Document the reasoning and safety-net. Code the suspected diagnosis so out-of-hours services can see it.
After Discharge (within ~1–2 weeks) — GP Review
Read the discharge and endocrinology letters. Put hydrocortisone, fludrocortisone and the IM kit on repeat with enough sick-day supply. Code the record and add an alert. Check the Steroid Emergency Card has been issued. Nurse appointment to train Hannah and a household member to give the injection. Go through the sick-day rules using teach-back. Check symptoms and postural BP.
4–12 Weeks — Titration (Endocrinology-Led, GP Supports)
Energy, appetite, weight, pigmentation and postural drop. U&E, with renin requested by the specialist for fludrocortisone titration. Signs of over-replacement. Autoimmune screen results (TFTs, B12, coeliac serology, HbA1c) acted on. PHQ-9 if mood has not improved. Return-to-work planning.
Before Any Procedure, Pregnancy or Long Trip
Surgery, endoscopy, significant dental work: make sure the team knows and cover is planned (AAGBI/RCP/SfE 2020). Pregnancy: early joint obstetric–endocrine referral. Travel: extra supply, kit in hand luggage, doctor's letter.
Annually — Shared-Care Review
Annual specialist review (site protocol), plus GP checks: wellbeing, weight, lying/standing BP, U&E, glucose or HbA1c, autoimmune cluster tests (TFTs, B12, coeliac serology) when clinically indicated, bone health where relevant. Sick-day rules re-taught; kit expiry; card carried; any crises or ED visits reviewed. Seasonal vaccines per UKHSA eligibility.
Memory rule — monitoring in adrenal insufficiency
At every contact: How do you feel? (under- vs over-replacement), lying/standing BP + weight, U&E (primary disease), sick-day rules re-taught, kit in date and someone trained, card carried. When clinically indicated (symptoms, history, previous results): the autoimmune cluster (thyroid, B12, glucose, coeliac). Periodically: bone health. Never titrate to a random cortisol.
| What | Test / check | When | Action threshold |
|---|---|---|---|
| Glucocorticoid adequacy | Symptoms, weight, pigmentation, BP | Every review | Fatigue, nausea, weight loss, pigmentation → possible under-replacement: discuss increasing the dose. Weight gain, insomnia, hypertension, rising glucose → possible over-replacement. |
| Mineralocorticoid adequacy (primary) | Lying/standing BP, oedema, U&E, plasma renin (specialist) | Each review; renin as the specialist directs | Postural drop, low Na, high K, salt craving, high renin → too little. Hypertension, oedema, low K, suppressed renin → too much. |
| Hyponatraemia or hyperkalaemia on routine bloods | U&E | Whenever found | Unwell + abnormal electrolytes → same-day assessment and treat as impending crisis. Well → repeat soon and discuss with endocrinology. |
| Thyroid | TSH ± fT4 | At diagnosis, then when clinically indicated | Autoimmune thyroid disease is the commonest association. Replace glucocorticoid first if both are deficient. |
| Type 1 diabetes / dysglycaemia | Glucose / HbA1c | At diagnosis, then when clinically indicated | New T1DM symptoms → same-day glucose and ketones. Recurrent hypos in known T1DM → review adrenal cover. |
| Pernicious anaemia, coeliac disease | FBC, B12; coeliac serology | At diagnosis; B12 periodically; coeliac if symptoms or unexplained anaemia | Low B12 → investigate and replace. Positive serology → gastroenterology referral. |
| Premature ovarian insufficiency (women, APS-2) | Menstrual history; FSH if amenorrhoea | At review | Amenorrhoea or menopausal symptoms under 40 → investigate; refer as per POI guidance. |
| Bone health | Fracture risk (FRAX), DXA where indicated | Periodically; more often if on higher doses or prednisolone | Over-replacement increases bone loss, so minimise the dose. Manage osteoporosis per NOGG. |
| Crisis readiness | Card, alert ID, kit expiry, trained second person, sick-day teach-back | Every contact | Any gap → fix today: reissue card, prescribe kit, book training. |
| Mood and quality of life | PHQ-9 / GAD-7, fatigue | At diagnosis, then at review | Persistent low mood → treat in its own right (do not assume it is just cortisol). Residual fatigue on adequate replacement → specialist review. |
⚠ Three scenario-specific phrases — use these verbatim
Why safety-netting matters beyond clinical care
- Not teaching sick-day rules / emergency kit / alert card
- Not warning never to stop steroids abruptly
- Treating crisis without parenteral hydrocortisone
Who you are
Hannah Whitfield, 38. Third visit in four months for overwhelming tiredness, low mood and poor appetite. You've lost about 6kg without trying, feel dizzy/light-headed standing up, and have started craving salty foods (you put extra salt on everything). Previous GPs said "stress/burnout" and possibly depression, which never sat right. Friends keep saying how tanned you look though you've not been in the sun, and your old appendix scar has gone dark. You have vitiligo; your mum has an underactive thyroid. Today you also feel nauseated and "wiped out".
Hidden concerns (reveal if explored)
Not being believed (main): you're worried you'll be fobbed off again. If the doctor takes you seriously, you're hugely relieved.
Cancer fear: the weight loss frightens you.
The tan: you think it's odd but didn't think it mattered — you'll mention it if asked about skin changes.
Clinical details if asked
- Fatigue, weight loss ~6kg, anorexia, nausea; dizzy on standing; salt craving
- Skin darkening — palms creases, gums, old scar; friends comment on "tan"
- Vitiligo; mother hypothyroid; no steroid tablets/inhalers/creams ever
- Low mood but you feel it's physical; no specific suicidal thoughts
- Today: nausea, feels wiped out; light-headed standing (postural drop on exam); no vomiting yet
- No recent foreign travel/TB contact that you know of
Reactions at key moments
- On being taken seriously: visibly relieved, tearful — "thank you, I knew something was wrong."
- On the skin question: "Yes! Everyone says I look tanned and I haven't been anywhere."
- On urgent assessment today: a little frightened but reassured it's to be safe.
- On lifelong treatment: daunted but relieved there's an answer and a treatment.
- Challenge line: "It's not just stress, is it? Please tell me what you actually think is going on."
Resolution: Hannah is helped if the GP: (1) takes her seriously and steps back from the "stress/burnout" label, pulling the cluster together (fatigue, weight loss, salt craving, postural dizziness, pigmentation, autoimmune background); (2) elicits/looks for hyperpigmentation and checks postural BP; (3) recognises she is decompensating today (nausea, postural hypotension) and arranges urgent same-day assessment, knowing crisis is treated with parenteral hydrocortisone before results; (4) checks U&E/glucose/9am cortisol and explains the Synacthen pathway and urgent endocrine referral; (5) conveys the serious-but-treatable diagnosis, and (once confirmed/initiated) teaches never to stop steroids, sick-day rules, the emergency kit and alert card. She is failed if dismissed again or sent home to await a routine test while decompensating.
- Shock, vomiting, confusion
- Postural hypotension + nausea
- Symptomatic / low 9am cortisol
- Low Na, high K
- 9am cortisol, U&E, glucose
- Synacthen, ACTH, autoimmune screen
Crisis: immediate IV/IM hydrocortisone 100mg + IV saline + glucose; treat precipitant; don't await results. Lifelong: hydrocortisone + fludrocortisone (primary), specialist-initiated; never stop abruptly. Safety education: sick-day rules (extra 20 mg then at least 40 mg hydrocortisone/day for illness; parenteral if vomiting), emergency hydrocortisone injection kit, steroid emergency card + medical-alert ID. Screen autoimmune associations; specialist follow-up.