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CPE-008 · synthetic case ADR-FX-12
Blood pressure 78/40, known adrenal insufficiency, vomiting
A possible adrenal crisis.
Purpose: A possible adrenal crisis.
Inputs the engine received
Chemistry and vitals
- Age
- 49 years
- Sodium
- 126 mmol/L
- Potassium
- 5.9 mmol/L
- Systolic BP
- 78 mmHg
Symptoms and signs
- Nausea or vomiting
- Yes
Exposures, history and context
- Known adrenal insufficiency
- Yes
- Fever, vomiting, diarrhea, trauma or surgery
- Yes
What the engine reports
Hypotension with a recognized risk for adrenal insufficiency is an emergency. Treat first per protocol and do not wait for test results; draw cortisol and ACTH only if it does not delay treatment. The engine names no dose.
Sick-day rules apply: glucocorticoid cover is increased per the patient's own plan, and parenteral treatment is needed if vomiting. Dose and route belong to the treating physician and the written plan.
Detected clinical pattern
Urgent Review Finding
A safety rule calls for urgent clinical assessment. Read the safety findings first.
- Pattern: screening indicated
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Emergency treatment per adrenal-crisis protocol; do not wait for laboratory confirmation.
- 2Apply the patient's sick-day plan; parenteral glucocorticoid is needed if vomiting.
- 3Order an 8 am cortisol with ACTH; add renin and aldosterone when primary insufficiency is suspected.Endocrine Society 2016.
Missing information
- 8 am cortisol and ACTH.
Evidence and rule trace · 3 rules
AI-01Clinical and laboratory pattern that justifies testing
Inputs: sodium 126 · potassium 5.9 · nausea or vomiting
Screening opportunity: measure an 8 am cortisol with ACTH.
AI-12Possible adrenal crisis
Inputs: systolic blood pressure 78 mmHg · known adrenal insufficiency · sodium 126 · potassium 5.9
Emergency: suspected adrenal crisis.
AI-13Known adrenal insufficiency with intercurrent illness
Inputs: known adrenal insufficiency · fever, vomiting, diarrhea, trauma or surgery
Sick-day rules apply.
Evidence
- EV-ES-PAI-2016 · Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
- EV-HUSEBYE-2014 · Husebye ES, Allolio B, Arlt W, et al. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. J Intern Med. 2014;275(2):104-115.
- EV-RUSHWORTH-2019 · Rushworth RL, Torpy DJ, Falhammar H. Adrenal Crisis. N Engl J Med. 2019;381(9):852-861.
Physician adjudication required. Clinical decision support for physician review. This output identifies laboratory patterns and safety situations. It does not diagnose adrenal insufficiency, name a glucocorticoid dose, or replace emergency treatment. Physician adjudication is required.
Change the values
The same engine, starting from this case. Change any value and watch the pattern and the rule trace react.
Cortisol testing
- <5 very likely
- 5–14.9 indeterminate
- ≥15 unlikely
46 pg/mL is assumed when empty.
Chemistry and vitals
Symptoms and signs
Exposures, history and context
More adrenal cases
ADR-FX-01
Low sodium, high potassium, weight loss and nausea
A 44-year-old with hyperpigmented scars.
ADR-FX-02
Hyperpigmentation and fatigue
No labs yet.
ADR-FX-03
Salt craving and dizziness on standing
Low sodium.
ADR-FX-04
Cortisol 2.1 with ACTH 180
Low cortisol and high ACTH: a primary pattern.
ADR-FX-05
Morning cortisol 9 µg/dL
Indeterminate.
ADR-FX-06
Morning cortisol 17 µg/dL
Unlikely.
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