Subjective
Date of visit
Reason for visit (follow-up for primary adrenal insufficiency [PAI], evaluation of new symptoms)
Current symptoms:
Fatigue (severity and impact on daily life)
Weakness
Weight loss or gain (appetite changes)
Nausea, vomiting, or abdominal pain
Skin hyperpigmentation (darkening) – a classic finding in PAI
Salt cravings
Mood changes (irritability, depression)
Stressful events or illnesses since last visit
Medication adherence (corticosteroids, mineralocorticoids)
Social history:
Access to medications and follow-up care
Objective
Vital signs (temperature, blood pressure, heart rate, weight) – low blood pressure and weight loss can be seen
Physical exam:
General (assessing for dehydration, muscle wasting)
Skin (looking for hyperpigmentation)
Mucous membranes (dryness)
Orthostatic hypotension (blood pressure drop upon standing)
Laboratory Tests
Basic metabolic panel (BMP):
Electrolytes (may show low sodium, high potassium)
Blood sugar (may be low)
Kidney function
Adrenocorticotropic hormone (ACTH) level: elevated in PAI due to the pituitary gland trying to stimulate the adrenal glands
Cortisol level: low in PAI
Assessment
Primary adrenal insufficiency (confirmed by clinical presentation, laboratory findings)
Severity of PAI (based on symptoms and blood work)
Evaluation for potential causes (autoimmune disease, tuberculosis) – may require further investigation
Adherence to medication regimen
Management of stress (important for PAI patients)
Plan
Medication adjustments (corticosteroid and/or mineralocorticoid dose) based on symptoms and lab results
Stress management education (importance of coping mechanisms)
Consideration of stress-dose steroid adjustments for anticipated stressful events (illness, surgery)
Referral to endocrinologist for further management (if needed)
Education
Explain primary adrenal insufficiency, its causes, and symptoms.
Review the importance of medication adherence and not abruptly stopping medications.
Discuss the signs and symptoms of adrenal crisis (sudden worsening of symptoms requiring immediate medical attention).
Provide information on stress management techniques.
Educate the patient on wearing a medical alert bracelet indicating PAI diagnosis.
Follow-up
Schedule for follow-up appointments:
Monitor response to medication adjustments
Assess for medication side effects
Address any ongoing challenges or concerns
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of primary adrenal insufficiency.