07:20
Vomiting and missed hormone replacement have left the patient hypotensive and hypoglycemic. Recognize the endocrine emergency before the full laboratory panel returns.
Provider note
CC: “I keep throwing up and feel like I might pass out.”
HPI: A 44-year-old woman with known postsurgical hypopituitarism presents after 36 hours of vomiting and poor intake. She missed four scheduled hydrocortisone doses and two levothyroxine doses because she could not keep pills down. Her partner reports unusual sluggishness this morning. No severe headache, new vision change, focal weakness, or head injury.
PMH: Pituitary macroadenoma resected transsphenoidally in 2022; central adrenal insufficiency and central hypothyroidism; no known diabetes.
Family / social: Mother has hypothyroidism. Lives with partner, works as a librarian, does not smoke, drinks alcohol rarely. No emergency steroid injection available at home.
ROS: Positive for fatigue, dizziness, nausea, and vomiting; negative for chest pain, dyspnea, dysuria, and focal neurologic symptoms.
Exam: Drowsy but arousable, dry mucous membranes, cool hands, tachycardia, no focal deficit or visual field complaint; abdomen soft with mild diffuse discomfort and no guarding.
Labs / diagnostics: POC glucose 49 mg/dL, sodium 124 mmol/L; predose cortisol and ACTH collected before steroid administration. ECG shows sinus tachycardia. No acute neuroimaging indication on this exam; reassess if new headache, vision change, or focal deficit develops.
Assessment: Suspected adrenal crisis due to central ACTH deficiency, precipitated by vomiting and inability to take hydrocortisone. Hypoglycemia, hypotension, and hyponatremia support impaired cortisol response; volume depletion may contribute. Differential includes infection and other causes of shock if response is inadequate.
Plan: Give IV dextrose, immediate parenteral hydrocortisone, and isotonic fluid with frequent reassessment. Trend glucose, sodium, perfusion, mental status, and urine output; request endocrinology consultation. Defer oral thyroid replacement until glucocorticoid coverage is established and oral intake is tolerated.
Dr. Zoe Langston, MD · Emergency Medicine
Current provider orders
| Order type | Order details | Priority | Ordered by | Status | Comments |
|---|---|---|---|---|---|
| Admission | ED observation; step-down if needed | Stat | Dr. Zoe Langston, MD | Active | Adrenal crisis precautions; reassess level of care. |
| Medication | Hydrocortisone 100 mg IV once at 07:32 | Stat | Dr. Zoe Langston, MD | Completed | Suspected adrenal crisis; do not wait for hormone results. |
| Medication | Hydrocortisone 50 mg IV every 6 hr starting 13:32 for initial 24 hr; reassess | Stat | Dr. Zoe Langston, MD | Active | Stress-dose cortisol replacement; endocrinology to guide taper. |
| IV fluid | 0.9% sodium chloride 1,000 mL IV over 1 hr; further fluid by reassessment | Stat | Dr. Zoe Langston, MD | Completed | Hypotension/volume depletion; monitor lungs, BP, and urine output. |
| Medication | Dextrose 25 g IV once at 07:27 | Stat | Dr. Zoe Langston, MD | Completed | POC glucose 49 mg/dL; recheck per hypoglycemia protocol. |
| Lab | BMP and point-of-care glucose now; repeat BMP at 10:40 and 16:00 | Stat | Dr. Zoe Langston, MD | In progress | Trend sodium, glucose, potassium, and renal function. |
| Monitoring | Vital signs every 15 min until stable, then hourly; strict intake/output | Stat | Dr. Zoe Langston, MD | Active | Report recurrent hypotension, confusion, or hypoglycemia. |
| Consult | Endocrinology consultation | Urgent | Dr. Zoe Langston, MD | Requested | Known hypopituitarism; guide steroid and thyroid replacement. |
Nursing note
Patient states, “I missed my steroid pills because I threw everything up.” Drowsy but awakens to voice and follows commands; partner confirms this is below her usual alertness. BP 82/48, HR 118, POC glucose 49 mg/dL; skin cool and oral mucosa dry. Two peripheral IVs placed, both sites clean, dry, and patent. Dr. Langston notified of hypotension and hypoglycemia on arrival. Dextrose given at 07:27, blood drawn for ordered studies before hydrocortisone, hydrocortisone administered at 07:32, and 0.9% saline started. Rechecking glucose and vital signs per orders; fall precautions in place and partner updated at bedside.
Vital signs
| Vital sign | 07:20 | Reference* |
|---|---|---|
| Temperature | 37.8°C / 100.0°F | 36.1–37.2°C |
| Heart rate | 118 bpm | 60–100 bpm |
| Respiratory rate | 22/min | 12–20/min |
| Blood pressure | 82/48 mmHg | Interpret in clinical context |
| SpO₂ | 97% RA | 95–100% |
| Pain | 2/10 | Patient reported |
| POC glucose | 49 mg/dL | 70–99 mg/dL fasting* |
*General adult examples. The glucose reference is a fasting range; bedside targets depend on clinical context.
Labs
| Lab test | 07:20 | Reference* |
|---|---|---|
| Sodium | 124 L | 135–145 mmol/L |
| Potassium | 4.1 | 3.5–5.0 mmol/L |
| Serum glucose | 52 L | 70–99 mg/dL fasting* |
| BUN | 24 H | 7–20 mg/dL |
| Creatinine | 1.1 | 0.6–1.2 mg/dL |
| Free T4 | Collected; pending | 0.8–1.8 ng/dL |
| TSH | Collected; pending | 0.4–4.0 mIU/L |
| Cortisol, predose | Collected; pending | Timing and assay matter |
| ACTH, predose | Collected; pending | ~7–63 pg/mL† |
*Illustrative ranges; use the reporting laboratory’s intervals. †ACTH range varies substantially by assay. Predose hormones were collected before IV hydrocortisone; repeat cortisol while receiving hydrocortisone would not assess endogenous production.
Diagnostics
- 07:24 ECG completed: sinus tachycardia, approximately 118 bpm; no acute ischemic changes reported.
- No brain imaging ordered at this point; no new severe headache, vision loss, or focal deficit.
- Predose endocrine blood samples collected; initial cortisol and ACTH results are pending at the bedside decision point.
Significant events
- 07:27 — Dextrose 25 g IV administered for POC glucose 49 mg/dL.
- 07:32 — Hydrocortisone 100 mg IV administered; treatment was not delayed for cortisol result.
- 07:35 — Isotonic fluid bolus begun; repeat bedside glucose and hemodynamic checks planned.
Pause & decide
Hypotension (82/48), hypoglycemia (POC 49), and altered alertness in a person who missed hydrocortisone strongly suggest adrenal crisis. Hyponatremia and vomiting add support, although each finding alone has other possible causes. The nurse should promptly alert the provider, treat the low glucose according to orders, obtain IV access, and give ordered parenteral hydrocortisone and isotonic fluid while repeatedly checking perfusion and mental status. A predose cortisol specimen is useful if readily obtainable, but it must not delay steroid treatment.
This patient cannot increase her own cortisol output during illness because pituitary ACTH production is deficient. Vomiting both stresses the body and prevents reliable absorption of oral hydrocortisone, so her usual replacement becomes inadequate or is missed entirely. Blood pressure and glucose can fall quickly, and hyponatremia or confusion can worsen. Sick-day instructions and an emergency injection plan are essential because a seemingly routine stomach illness can trigger a life-threatening crisis.