Diagnose It Answer — April 27, 2026

41-year-old female presents in acute distress with severe abdominal pain, profound weakness, and confusion. Her husband states she has had nausea and vomiting for 3 days and has been unable to keep any medications down. He noticed she collapsed while trying to get to the bathroom. She looks 'gray' and has barely been conscious during the car ride in.

Known diagnosis of Addison's disease (primary adrenal insufficiency) diagnosed 4 years ago, managed with hydrocortisone 20mg in the morning and 10mg in the evening, plus fludrocortisone. She has been vomiting for 3 days due to a GI illness and could not take her oral hydrocortisone. Her husband was unaware she needed to increase her dose during illness (sick day rules). She did not have injectable hydrocortisone at home.

BP 74/46 mmHg (orthostatic — unresponsive to position), HR 128 bpm, RR 22 breaths/min, Temp 38.6°C, SpO2 96% on room air. Patient is obtunded — GCS 9 (E2 V3 M4). Skin appears bronze/hyperpigmented at the knuckles, elbows, and buccal mucosa — chronic finding of primary adrenal insufficiency. Severe volume depletion clinically evident.

Adrenal crisis diagnosed clinically — laboratory results ordered but treatment NOT delayed pending results, as this is life-threatening. Hydrocortisone 100mg IV bolus given immediately — followed by continuous infusion at 200mg over 24 hours. 1L normal saline IV wide open (normal saline is preferred over D5W in this context — sodium replacement is critical). Dextrose 50% IV given after glucose confirmed low. Patient will require IV hydrocortisone and close monitoring until she can tolerate oral medications. Endocrinology consulted. Family education on sick day rules initiated.

Serum cortisol drawn before hydrocortisone: 2.1 µg/dL (critically low; a value <3 µg/dL in a critically ill patient is diagnostic of adrenal insufficiency). ACTH stimulation test deferred — patient too unstable. Na 126 mEq/L (hyponatremia — aldosterone deficiency impairs sodium retention). K 6.1 mEq/L (hyperkalemia — aldosterone deficiency impairs potassium excretion). Glucose 48 mg/dL (hypoglycemia — cortisol is a gluconeogenic hormone). BUN 38 mg/dL, creatinine 1.8 mg/dL (pre-renal AKI from volume depletion). ACTH level sent: will return markedly elevated in primary adrenal insufficiency.