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CPE-008 · synthetic case ADR-FX-16
Cortisol 8 µg/dL drawn at 2 pm
Afternoon sample.
Purpose: Afternoon sample.
Inputs the engine received
Cortisol testing
- 8 am total cortisol
- 8 µg/dL
- Sample drawn after 10 am
- Yes
Chemistry and vitals
- Age
- 53 years
Symptoms and signs
- Fatigue
- Yes
What the engine reports
sample drawn after 10 am. Treat the cortisol as provisional and repeat an 8 am cortisol with ACTH after the confounder is addressed, or use an ACTH-stimulation test.
Detected clinical pattern
Indeterminate Morning Cortisol — Stimulation Test Needed
A morning cortisol between 5 and 15 µg/dL does not settle the question.
Why this pattern was identified
- Morning cortisol. 8 µg/dL: indeterminate, an ACTH-stimulation test is needed (Endocrine Society; consensus statement).
Recommended next steps
For physician consideration. Urgent review always comes first.
- 1Repeat an 8 am cortisol with ACTH after the confounder is addressed, or use an ACTH-stimulation test.
- 2Perform an ACTH-stimulation test (250 µg cosyntropin) to settle an indeterminate morning cortisol.
Missing information
- ACTH (to separate primary from secondary adrenal insufficiency).
Evidence and rule trace · 3 rules
AI-VAL-01Cortisol result may be unreliable
Inputs: sample drawn after 10 am
Total cortisol may mislead; interpretation is provisional.
AI-04Morning cortisol band
Inputs: 8 am cortisol 8 µg/dL
Indeterminate (5 to <15 µg/dL): an ACTH-stimulation test is needed.
AI-MISS-01ACTH needed to place the axis
Inputs: low cortisol or insufficient stimulation · ACTH not entered
Primary versus secondary cannot be separated without ACTH.
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-ES-GCAI-2024 · Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024;109(7):1657-1683.
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.
Morning cortisol bands
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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