Endocrine & Metabolic · Full case

Addison's Disease

NICE CKS / Soc. Endo.Short SynacthenAdrenal crisis

The great mimicAddison's presents with non-specific symptoms — fatigue, weight loss, anorexia, nausea, dizziness, low mood — that mimic depression, chronic fatigue, anorexia and viral illness. It is frequently diagnosed late, often only at adrenal crisis. Keep it in mind in unexplained chronic fatigue with weight loss

Pigmentation is the clueHyperpigmentation (palmar creases, buccal mucosa, scars, pressure areas) from high ACTH is the most specific sign of PRIMARY adrenal insufficiency. Postural hypotension and salt craving also point to it

Low Na, high KThe classic biochemistry: hyponatraemia, hyperkalaemia, ± hypoglycaemia and mild metabolic acidosis. Unexplained low Na/high K in a tired, weight-losing patient should prompt urgent consideration of adrenal insufficiency

9am cortisol then SynacthenScreen with a 9am serum cortisol; a low/equivocal value needs a short Synacthen (ACTH stimulation) test to confirm. Paired ACTH (high in primary, low in secondary) localises the cause

Adrenal crisis = emergencyAdrenal (Addisonian) crisis — hypotension/shock, vomiting, abdominal pain, confusion, profound weakness, often precipitated by infection/illness/missed steroids — is life-threatening. Give IV/IM hydrocortisone IMMEDIATELY and fluids; do not wait for test results

Steroids for lifeTreatment is lifelong glucocorticoid (hydrocortisone) + mineralocorticoid (fludrocortisone) replacement. Patients must never abruptly stop steroids — this itself can precipitate a crisis

Sick-day rulesDuring illness, fever, surgery or vomiting, the steroid dose must be DOUBLED (or given parenterally if vomiting). Every patient needs sick-day rules, an emergency hydrocortisone injection kit, and a steroid emergency card / medical-alert ID

Think autoimmune companyAutoimmune Addison's clusters with other autoimmune disease (thyroid, type 1 diabetes, pernicious anaemia, coeliac, vitiligo) — autoimmune polyendocrine syndromes. Screen associated conditions; TB and metastases are other causes worldwide

📋 Clinical Stem — Addison's Disease

A 38-year-old woman with months of "burnout" — exhaustion, weight loss, dizziness and salt craving — repeatedly attributed to stress, now looking tanned despite no sun

Hannah Whitfield, 38, attends for the third time in four months with overwhelming tiredness, low mood and "no appetite". She has lost about 6kg without trying, feels dizzy on standing, and has started craving salty food. Previous visits diagnosed "stress/burnout" and possible depression. She mentions, almost in passing, that friends keep saying how tanned she looks even though she hasn't been in the sun, and that her old appendix scar has gone dark. She has vitiligo and her mother has an underactive thyroid. Today she also feels nauseated and "wiped out", and her blood pressure is low with a marked postural drop.

This stem tests the ability to: recognise Addison's disease behind a "burnout/depression" presentation — the great mimic — by pulling together fatigue, unintentional weight loss, anorexia/nausea, postural dizziness, salt craving and (the specific clue) hyperpigmentation in a patient with personal/family autoimmune disease; check the right initial bloods (U&E for low Na/high K, glucose, 9am cortisol) and arrange/seek the short Synacthen test; recognise the features of impending adrenal crisis (postural hypotension, nausea, intercurrent stress) and know that crisis is treated immediately with parenteral hydrocortisone and fluids without waiting for results; explain lifelong steroid replacement, sick-day rules, the emergency injection kit and steroid alert card; and screen for associated autoimmune conditions. The SCA challenge is taking a repeatedly dismissed woman seriously, and conveying a serious lifelong diagnosis with appropriate safety-netting.

Scenario A — New diagnosis from chronic symptoms (this stem) The mimic picture + pigmentation + autoimmune background. Bloods (U&E, glucose, 9am cortisol, ACTH), Synacthen, urgent endocrine referral; assess for impending crisis; safety-net.

Scenario B — Adrenal crisis (EMERGENCY) Hypotension/shock, vomiting, abdominal pain, confusion, often precipitated by infection or missed doses. Immediate IV/IM hydrocortisone + fluids + glucose; 999/admit; don't wait for tests.

Scenario C — Known Addison's, intercurrent illness Established patient with infection/vomiting/surgery. Apply sick-day rules (double dose or parenteral); emergency injection if vomiting; low threshold for admission.

Scenario D — Secondary adrenal insufficiency Long-term/abruptly stopped exogenous steroids, or pituitary disease. No hyperpigmentation; ACTH low; aldosterone usually preserved. Steroid-withdrawal/pituitary management.

Scenario E — Autoimmune polyendocrine screen Coexisting thyroid disease, type 1 diabetes, pernicious anaemia, coeliac, vitiligo. Screen and monitor associated conditions.

Key variables to adapt for Chronic insidious vs acute crisis; primary (pigmentation, high ACTH, low Na/high K) vs secondary (no pigmentation, low ACTH, steroid history); precipitants (infection, surgery, missed/stopped steroids); autoimmune associations; sick-day rules & emergency kit; pregnancy; the repeatedly-dismissed patient.

Steps:

Step 1

History — The Mimic · Specific Clues · Crisis Features · Autoimmune Background · ICE

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The history's job is to lift Addison's out of the "burnout/depression" pile by recognising the specific clues hidden among non-specific symptoms — hyperpigmentation, salt craving, postural dizziness, and an autoimmune background — and to spot the features that signal an impending adrenal crisis. Hannah has been dismissed twice; the skill is to take the cluster seriously rather than re-label it as stress.

🎓 SCA framing — take the dismissed patient seriously

"You've been back a few times feeling exhausted and losing weight, and I don't think we've got to the bottom of it yet. Some of what you're describing — the weight loss, the dizziness, the salt craving, the tan — makes me want to check a specific hormone problem rather than just put it down to stress."

Validating that the symptoms are real and not yet explained — rather than re-anchoring on "stress" — is both good medicine and good communication. The weight loss + pigmentation cluster is the pivot.

1A — Symptoms, specific clues and crisis features

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me everything that's been going on — not just the tiredness, but anything else you've noticed, even things that seem unrelated."	An open invitation surfaces the cluster. Fatigue and low mood alone read as depression; add unintentional weight loss, anorexia, nausea, postural dizziness, salt craving and pigmentation and the picture changes entirely. Inviting "unrelated" details is what lets a patient mention the tan and the darkened scar.In SCA: recognising a pattern across previously separate complaints is the core diagnostic skill this case rewards.	Cluster → adrenal insufficiency, not depression
🚩 Specific clues"Have you noticed your skin getting darker — in your palm creases, gums, or old scars? Any craving for salt? Do you feel dizzy or faint when you stand?"	These are the discriminators. Hyperpigmentation (palmar creases, buccal mucosa, scars, pressure points) from high ACTH is the most specific sign of primary adrenal insufficiency; salt craving and postural symptoms reflect mineralocorticoid deficiency. Hannah has all three. They convert a vague picture into a testable hypothesis.	Pigmentation + salt craving + postural symptoms → test for Addison's.	U&E, glucose, 9am cortisol → Synacthen
🚩 Crisis / decompensation features"Are you vomiting, having tummy pain, feeling confused or very weak today? Any recent infection or illness?"	Nausea, vomiting, abdominal pain, postural hypotension, profound weakness and confusion — especially with an intercurrent stressor (infection, illness) — herald adrenal crisis. Hannah is nauseated with marked postural hypotension today: she is on the edge of decompensation and must not simply be sent home to await an outpatient test.	Crisis features → emergency parenteral hydrocortisone + fluids + admission; don't await results.	Crisis features → emergency treatment/admit
Autoimmune & cause background"Do you or your family have any autoimmune conditions — thyroid, type 1 diabetes, vitiligo, pernicious anaemia, coeliac? Any TB risk?"	Autoimmune adrenalitis is the commonest cause in the UK and clusters with other autoimmune disease (Hannah has vitiligo; her mother has thyroid disease). Worldwide, TB is important; metastases and adrenal haemorrhage are other causes. The background raises pre-test probability and prompts screening of associated conditions.	Autoimmune background → higher probability; screen associated conditions.	TFTs, B12, coeliac, glucose screen
Steroid & drug history"Have you taken steroid tablets, inhalers, creams or injections — recently or long-term? Stopped any suddenly?"	Distinguishes primary (Addison's) from secondary adrenal insufficiency. Long-term or abruptly-stopped exogenous steroids cause secondary insufficiency (no pigmentation, low ACTH). Crucial for both diagnosis and the warning never to stop steroids abruptly.	Exogenous steroid history → secondary insufficiency / withdrawal; no pigmentation.	Primary vs secondary
Mood & impact"How has your mood been, and how is all this affecting your life and work?"	Low mood is genuinely part of Addison's (and was the previous misdiagnosis). Acknowledging it — while not stopping there — both validates her and avoids dismissing the depression that may coexist. The functional impact frames urgency and support.	Low mood as part of the illness; treat the cause, support mood.	Validate mood; don't re-anchor on depression

1B — Red flags

🚨

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

1C — ICE

💭 Ideas

"What do you think has been making you feel so unwell — and how did you feel about the 'stress' explanation?"

Hannah may have accepted, or quietly doubted, the burnout label. Surfacing this lets you validate that her symptoms are real and physical, and explain why you now suspect a specific, treatable hormone problem — rebuilding trust eroded by being dismissed.

😟 Concerns

"What's worried you most — and has anything frightened you about how you've been feeling?"

She may fear cancer (weight loss), or that she won't be believed again. Naming her concerns lets you address them and explain the seriousness without alarming — and to convey that this, once diagnosed, is very treatable.

🎯 Expectations

"What were you hoping would happen today?"

She may expect another reassurance-and-home visit. Naming this lets you set out a clear plan — urgent bloods, a confirmatory test, specialist referral, and (given today's symptoms) possibly same-day assessment — so she leaves feeling finally taken seriously.

1D — Psychosocial context

Addison's is a textbook example of how non-specific symptoms in a busy clinic get repeatedly attributed to stress, depression or "being run down" — until the patient arrives in crisis. For Hannah, being told three times it is burnout is both a clinical hazard and a relational wound. The clinical act that matters is the willingness to step back from the inherited label, take the symptom cluster seriously, and look for the specific clue (pigmentation) — and to do so in a way that restores her sense of being believed.

🙇 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."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Have you noticed your skin darkening — palm creases, gums, old scars? Any salt craving?" — elicits the specific clues.

"Are you vomiting or feeling confused, and have you been ill recently?" — screens for impending crisis.

"I don't think this is just stress — your symptoms are real and I want to test for a specific cause." — validates & reframes.

Deductions

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

🔴 Red

Labels "stress" again; no specific clues sought; crisis features missed; no urgent bloods/assessment

🟠 Amber

Suspects organic cause; some clues elicited; bloods arranged but crisis risk underweighted; ICE partial

🟢 Green

Recognises the cluster + pigmentation; elicits salt craving/postural symptoms; spots impending crisis & acts; autoimmune background; urgent bloods + cortisol; ICE all three; validates the patient

Step 2

Triage — Adrenal Crisis · Urgent Endocrine · Routine Work-up

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The triage hinge is whether the patient is decompensating: crisis (or impending crisis) is an immediate emergency treated before any test; biochemically-suspected or symptomatic adrenal insufficiency needs urgent endocrine assessment; and a stable suspicious picture needs prompt confirmatory testing. Hannah's nausea and postural hypotension push her toward urgent same-day assessment.

🔴 Emergency

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

🟠 Urgent

Days

Endocrine

Symptomatic suspected Addison'sUrgent endocrinology; cortisol/ACTH + Synacthen
Low 9am cortisolExpedite confirmatory testing
Known patient, intercurrent illnessSick-day rules; review

🟢 Routine

Work-up

Confirm & screen

Stable suspicious picture9am cortisol, U&E, glucose; arrange Synacthen
Autoimmune screenTFTs, B12, coeliac, glucose
Established, stable Addison'sAnnual review; education

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"Because of the nausea and your blood pressure today, I want you assessed urgently — if this is an adrenal problem, the treatment is given straight away, before we even have the test back."

Deductions

Sending a decompensating patient home to await an outpatient test
Waiting for cortisol results before treating a crisis

Step 3

Examination — Pigmentation · Postural BP · Volume Status · Autoimmune Signs

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Examination looks for the specific sign (hyperpigmentation), quantifies the haemodynamic state (postural blood pressure, volume status — a marker of decompensation), and checks for associated autoimmune disease.

🔎 Specific & haemodynamic

Check	Why
Hyperpigmentation	Palmar creases, buccal mucosa, scars, pressure areas, recent — the specific sign of primary insufficiency.
Postural blood pressure	Postural drop reflects mineralocorticoid deficiency / volume depletion; a decompensation marker.
Volume/shock signs	Tachycardia, hypotension, dehydration — crisis.
Weight	Documents the unintentional loss.

🧬 Associated / cause

Check	Why
Vitiligo	Autoimmune association (Hannah).
Thyroid signs	Coexisting autoimmune thyroid disease.
General/abdominal exam	Exclude other causes of weight loss; assess for sepsis precipitant.
Mental state	Mood; confusion (crisis).

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Narration that scores

"I'll check your blood pressure lying and standing, look at your palms, gums and that scar for any darkening, and check for signs of dehydration — these point to the hormone problem I'm thinking of."

Deductions

Not checking postural BP; not looking for pigmentation
Missing signs of decompensation

Step 4

Investigations — U&E · 9am Cortisol · Short Synacthen · ACTH · Autoimmune Screen

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Investigation moves from the bedside biochemistry (U&E, glucose) and a 9am cortisol to the confirmatory short Synacthen test, with paired ACTH to localise primary vs secondary — and a screen for the associated autoimmune diseases. In a crisis, treatment precedes all of it (a random cortisol/ACTH can be taken before the first hydrocortisone dose, but never delay treatment).

🧪 Diagnostic

Test	Why
U&E	Hyponatraemia + hyperkalaemia — the classic pattern.
Glucose	Hypoglycaemia.
9am serum cortisol	Screening: low → likely insufficiency; very low is diagnostic; equivocal → Synacthen.
Short Synacthen (ACTH stimulation) test	Confirmatory: inadequate cortisol rise confirms adrenal insufficiency.
Plasma ACTH (paired)	High in primary (Addison's), low in secondary; localises the level.
Adrenal autoantibodies (21-hydroxylase)	Support autoimmune aetiology.

🔬 Aetiology & associations

Test	Why
TFTs	Autoimmune thyroid disease (common association).
B12, coeliac serology, glucose/HbA1c	Pernicious anaemia, coeliac, type 1 diabetes — polyendocrine clustering.
Renin/aldosterone	Assess mineralocorticoid axis (specialist).
Imaging / TB work-up	Adrenal CT or TB assessment where non-autoimmune cause suspected (specialist).

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"I'll check your salts and a morning cortisol level now. If that's low, we confirm it with a stimulation test the specialist arranges — and I'll also screen for related conditions like your thyroid."

Deductions

Delaying crisis treatment for test results
Not knowing the 9am cortisol → Synacthen pathway or the role of ACTH

Step 5

Diagnosis — Primary vs Secondary · Crisis · The Mimics

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Confirm adrenal insufficiency, localise it (primary Addison's vs secondary), identify any precipitant, and consciously hold the mimics — because the cost of mislabelling Addison's as depression or anorexia is a preventable crisis.

Diagnosis	Discriminating features
Primary adrenal insufficiency (Addison's)	Hyperpigmentation, low Na/high K, high ACTH, salt craving; autoimmune background (Hannah).
Secondary adrenal insufficiency	Exogenous steroids/pituitary disease; no pigmentation; low ACTH; aldosterone usually preserved.
Adrenal crisis	Acute decompensation — shock, vomiting, confusion; needs immediate treatment.
Depression / chronic fatigue	The common misdiagnosis — but no pigmentation, electrolyte changes or postural drop.
Malignancy / other	Weight loss differential; exclude as appropriate.

🚩 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).

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"I think your adrenal glands aren't making enough of an essential hormone — a condition called Addison's. It explains all your symptoms, including the tan. It's serious but very treatable: you replace the hormone, for life, and learn some rules for when you're ill."

Deductions

Not distinguishing primary from secondary
Accepting the depression label without excluding Addison's

Step 6

Referral — Emergency Admission · Urgent Endocrinology

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Suspected new Addison's is an endocrine diagnosis: crisis/decompensation needs emergency admission with immediate hydrocortisone, and a stable suspected case needs urgent endocrinology for confirmation and treatment initiation. GPs rarely start replacement alone.

Referral	Who / when	Urgency
🔴 Emergency admission	Adrenal crisis or impending crisis (give hydrocortisone + fluids first).	Same day / 999
Endocrinology (urgent)	Symptomatic suspected Addison's / low 9am cortisol — confirmation (Synacthen), treatment initiation, aetiology.	Urgent
Endocrinology (routine)	Stable suspicious picture; ongoing specialist management and monitoring.	Soon
Associated-condition care	Thyroid, diabetes, coeliac etc. screening/management.	As indicated

🎓 SCA Checkpoint — Step 6Tasks

Knowing the route

"Given how you are today, I'm going to arrange urgent assessment now — and the specialist endocrine team will confirm it and start the treatment that will get you feeling well again."

Deductions

Routine referral for a decompensating patient
Starting lifelong replacement without specialist confirmation in a stable case

Step 7

Management — Crisis Rx · Replacement · Sick-Day Rules · Emergency Kit · Education

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Management has two faces: the immediate, life-saving treatment of crisis (parenteral hydrocortisone + fluids, before tests), and the lifelong replacement and education that keep a patient safe — glucocorticoid + mineralocorticoid replacement, sick-day rules, an emergency injection kit, and a steroid alert card, with the absolute rule never to stop steroids.

7A — Acute and lifelong

🚑 Crisis & replacement

Element	Detail
Adrenal crisis	Immediate IV/IM hydrocortisone 100mg + rapid IV 0.9% saline + treat hypoglycaemia; identify/treat precipitant; admit. Do NOT await results.
Glucocorticoid replacement	Hydrocortisone (typically divided doses mimicking diurnal rhythm), specialist-initiated.
Mineralocorticoid replacement	Fludrocortisone in primary adrenal insufficiency (not usually needed in secondary).
Never stop abruptly	Abrupt cessation precipitates crisis — emphasise lifelong adherence.

🛡️ Education & safety-net

Element	Detail
Sick-day rules	Double the glucocorticoid dose for fever/illness; parenteral if vomiting/can't absorb; extra cover for surgery/procedures.
Emergency injection kit	IM hydrocortisone at home; patient/family trained to use it.
Steroid emergency card / alert ID	Carry a steroid card and wear medical-alert jewellery.
Screen associations	Thyroid, diabetes, B12, coeliac; monitor.
Review & support	Specialist follow-up; dose adjustment; psychological support; pregnancy/illness planning.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"The treatment is replacing the missing hormones, for life — and three safety rules: never stop your steroids, double the dose when you're ill, and use the emergency injection if you're vomiting. You'll carry a steroid card and wear an alert bracelet. The specialist will set the doses and review you."

Deductions

Not teaching sick-day rules / emergency kit / alert card
Not warning never to stop steroids abruptly
Treating crisis without parenteral hydrocortisone

"I'm back again — I'm sorry. I'm just exhausted all the time, I've lost weight, and I feel sick today. I was told it was stress and burnout, but I really don't think that's it. I feel dreadful."

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."

"Please be honest — it's not just stress or depression, is it? Something's really wrong and nobody's listened. What do you think it is?"

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.

🏥

Clinic Quick Reference

Addison's Disease — Clinical Decision Framework

The mimic · pigmentation/low Na high K · cortisol→Synacthen · crisis

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🚦 1 — Suspect & triage

Fatigue + weight loss + the clues

▼

🔴 Crisis

Shock, vomiting, confusion
Postural hypotension + nausea

IV/IM hydrocortisone + fluids; admit

🟠 Urgent

Symptomatic / low 9am cortisol
Low Na, high K

Urgent endocrine

🟢 Work-up

9am cortisol, U&E, glucose
Synacthen, ACTH, autoimmune screen

Confirm

💊 2 — Treat & safeguard

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 (double dose for illness; parenteral if vomiting), emergency hydrocortisone injection kit, steroid emergency card + medical-alert ID. Screen autoimmune associations; specialist follow-up.

🎓

SCA Quick Reference

Addison's — Consultation Playbook

See past "stress" · the clues · treat crisis first · steroids for life + sick-day rules

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🎯 The three pivots that pass this case

1 · See past the mimic

Fatigue + weight loss + pigmentation + salt craving + postural dizziness + autoimmune background = Addison's, not "stress".

2 · Crisis first

Decompensation → parenteral hydrocortisone + fluids before tests. Check U&E/glucose/9am cortisol → Synacthen.

3 · Steroids for life

Hydrocortisone + fludrocortisone; never stop; sick-day rules, emergency injection kit, steroid alert card.

⛔ Don't re-anchor on stress/depression and miss the cluster · Don't send a decompensating patient home to await a routine test · Don't wait for results to treat a crisis · Don't forget sick-day rules, the emergency kit and the alert card · Never advise stopping steroids abruptly

Addison's Disease · GP Clinical Reasoning Framework v2 · NICE CKS Addison's disease · Society for Endocrinology (adrenal insufficiency & crisis guidance) · steroid emergency card

The great mimic — fatigue/weight loss/anorexia/nausea/dizziness/low mood; suspect with hyperpigmentation, salt craving, postural hypotension, low Na/high K, autoimmune background · Screen 9am cortisol → confirm with short Synacthen; ACTH localises primary vs secondary · Adrenal crisis = immediate IV/IM hydrocortisone + fluids before results · Lifelong hydrocortisone + fludrocortisone; never stop abruptly · Sick-day rules, emergency injection kit, steroid emergency card / alert ID · Screen autoimmune associations

Teaching clinicians why each step matters — not just what to do · Always consult current NICE CKS and Society for Endocrinology guidance · Clinical judgement takes precedence over any framework

Addison's Disease

Red Flags — the crisis and the missed diagnosis

🙇 Being believed

⚖️ Serious but treatable

🆘 Why today matters

🧬 The autoimmune link

Now / 999

Days

Work-up

🚩 The discipline — name it before the crisis

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments