Signs

• Hypotension (less than 110/70 mm Hg) and orthostasis (87%)

• Dehydration, hypovolemia, and hyperkalemia (in primary adrenal insufficiency only) due to aldosterone deficiency.

• Decreased serum sodium and chloride levels due to aldosterone deficiency. Hy-ponatremia can also be present in secondary adrenal insufficiency due to cortisol deficiency and increased antidiuretic hormone secretion leading to subsequent water retention.

• Increased serum blood urea nitrogen and creatinine due to dehydration.

• Hyperpigmentation of skin and mucous membranes (92%). This is usually observed around creases, pressure areas, areolas, genitalia, and new scars. Dark freckles and patches of vitiligo may be present. Hyperpigmentation, due to increased ACTH levels, occurs in most patients with primary adrenal insufficiency but does not occur in secondary or tertiary adrenal insufficiency.

• Personality changes (irritability and restlessness) due to cortisol deficiency.

• Loss of axillary and pubic hair in women due to decreased androgen production.

• Blood count abnormalities (normocytic, normochromic anemia, relative lymphocytosis, neutrophilia, eosinophilia) due to cortisol and androgen deficiency.

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