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Evacuation/Consultation criteria: Evacuation is not typically necessary. Consult primary care physician,
internist or pulmonologist as needed. Enlarged tonsils and anatomic abnormalities usually require surgical
correction by an ENT surgeon.
NOTE: A diagnostic sleep study is recommended to make denitive diagnosis.
Chapter 4: Endocrine
Endocrine: Adrenal Insufficiency
Col Stephen Brietzke, USAF, MCIntroduction: Primary adrenal insufficiency, characterized by deficient production of cortisol and aldosterone,
can occur acutely due to hemorrhage or an infarction involving the adrenal circulation. Proximate causes
of such an event include gram-negative bacterial sepsis and blunt or penetrating abdominal trauma.
Acute adrenal insufficiency is a medical emergency, heralded by severe orthostatic hypotension, shock,
hyponatremia and often hyperkalemia. Sub-acute or chronic primary adrenal insufficiency is usually caused
by autoimmune disease (Addison’s disease) or metastatic cancer in developed countries, but in the developing
world, replacement of normal adrenal tissue by tuberculous infection is more prevalent. Secondary adrenal
insufficiency, characterized by deficient production of cortisol but normal production of aldosterone, is due
to some form of hypothalamic or pituitary gland disease. Chronic or sub-acute causes include tumors of
or near the pituitary gland. Acute causes include transection or infarction of the gland due to closed or
penetrating head trauma.
Subjective: Symptoms
Acute: Severe orthostatic hypotension or shock; severe, poorly localized abdominal pain; nausea; vomiting;
weakness; mood change; confusion or psychosis. Sub-acute and chronic: Fatigue, malaise, weight loss,
poor appetite, nausea, postural faintness or lightheadedness, loss of libido, depression, anxiety, confusion
or acute psychosis.
Focused History: Do you feel faint or pass out when you stand up? (low blood pressure) Do you have
nausea and vomiting? (poor general condition) Have you lost interest in sex? Are you having trouble thinking
clearly? Do you feel sad or depressed? (prominent symptoms) Do you have any abdominal pain? Where?
(usually, diffuse and poorly localized) How long have you felt ill? (if less than four weeks, may reflect an
urgent emergency) Do you feel better if you eat salty foods? Do you crave salty food and drink? (Since
sodium loss through the urine is responsible for volume depletion, salt craving is an adaptive response.)
Objective: Signs
Using Basic Tools: Acute Presentation (< 2-4 weeks onset): Orthostatic hypotension, tachycardia,
flank ecchymoses, fever > 100.4°F, confusion/disorientation, ileus/abdominal tenderness (mimicking “acute
abdomen”)
Sub-acute/Chronic Presentation (>4 weeks): Orthostatic hypotension (mild), hyperpigmentation (especially
palmar creases and scars), loss of muscle mass/loose skin folds, vitiligo
*BP < 100/60 or supine BP > 20 mm Hg higher than standing BP
Using Advanced Tools: Lab: Acute: Elevated WBC, platelets on CBC, hypoglycemia on urine dipstick.
Chronic: elevated platelets on CBC, hypoglycemia.
Assessment:
Definitive diagnosis will be beyond the capabilities of field laboratories (low sodium, high potassium, others).
Differential Diagnosis
Acute - other hypotensive states, including blood loss hypovolemia, volume depletion from gastroenteritis-
related vomiting and diarrhea, pancreatitis, and diabetic ketoacidosis.
Sub-acute/chronic - chronic infections, such as TB or malaria, metastatic cancer, diabetes mellitus,