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CPE-008 · synthetic case ADR-FX-15
Low free T4 with low TSH
Assess the adrenal axis before levothyroxine.
Purpose: Assess the adrenal axis before levothyroxine.
Inputs the engine received
Chemistry and vitals
- Age
- 45 years
Symptoms and signs
- Fatigue
- Yes
Exposures, history and context
- Low free T4 with low or normal TSH
- Yes
What the engine reports
A central hypothyroid pattern raises the possibility of pituitary disease. Levothyroxine can precipitate adrenal crisis in unrecognized insufficiency.
Detected clinical pattern
No Adrenal Screening Trigger
The values entered do not meet a screening pattern. Fatigue alone does not justify adrenal testing.
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Assess adrenal function before thyroid hormone replacement.
Evidence and rule trace · 1 rules
AI-15Central hypothyroidism: assess the adrenal axis first
Inputs: low free T4 with low or normal TSH
Assess the adrenal axis before thyroid hormone replacement.
Evidence
- EV-ES-HYPOPIT-2016 · Fleseriu M, Hashim IA, Karavitaki N, et al. Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(11):3888-3921.
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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