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CPE-008 · synthetic case ADR-FX-18
Cortisol 3.5, ACTH missing
The axis cannot be classified.
Purpose: The axis cannot be classified.
Inputs the engine received
Cortisol testing
- 8 am total cortisol
- 3.5 µg/dL
Chemistry and vitals
- Age
- 48 years
Symptoms and signs
- Fatigue
- Yes
What the engine reports
Detected clinical pattern
Low Cortisol — Axis Not Yet Classified
Cortisol is low or the stimulation response is insufficient. ACTH is needed to separate primary from secondary.
Why this pattern was identified
- Morning cortisol. 3.5 µg/dL: adrenal insufficiency is very likely (Endocrine Society; consensus statement).
Missing information
- ACTH (to separate primary from secondary adrenal insufficiency).
Evidence and rule trace · 2 rules
AI-04Morning cortisol band
Inputs: 8 am cortisol 3.5 µg/dL
Adrenal insufficiency very likely (<5 µg/dL).
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.
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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