From the Guidelines
Hypocortisolism (low cortisol) is typically diagnosed through a combination of clinical evaluation and laboratory tests, with key historical present illness (HPI) questions focusing on symptoms such as fatigue, weight loss, and skin changes.
Key HPI Questions for Hypocortisolism
- Symptoms:
- Fatigue or weakness
- Weight loss
- Loss of appetite
- Nausea or vomiting
- Dizziness or fainting
- Skin changes (darkening or thinning)
- Hair loss
- Muscle or joint pain
- Low blood pressure
- Medical History:
- Previous use of corticosteroids
- History of pituitary or adrenal gland problems
- Recent illness or infection
- Family history of adrenal insufficiency
- Medications:
- Current or past use of corticosteroids
- Other medications that may affect cortisol levels
Diagnostic Evaluation
As outlined in the study by 1, the diagnostic work-up for patients with suspected adrenal insufficiency should include:
- Laboratory tests:
- Morning cortisol level
- Adrenocorticotropic hormone (ACTH) level
- Basic metabolic panel (including sodium, potassium, and glucose)
- Additional tests:
- ACTH stimulation test (if initial results are indeterminate)
- Adrenal CT scan (to evaluate for metastasis or hemorrhage)
Management Considerations
According to the guidelines outlined in 1 and 1, management of hypocortisolism typically involves:
- Corticosteroid replacement therapy:
- Hydrocortisone (15-20 mg/day in divided doses)
- Fludrocortisone (0.05-0.1 mg/day) for primary adrenal insufficiency
- Education on stress dosing and emergency procedures:
- Patients should be educated on how to increase their corticosteroid dose during times of stress (e.g., illness, surgery)
- Patients should also be instructed on how to use emergency injectable corticosteroids and when to seek medical attention.
From the Research
Historical Present Illness (HPI) Questions for Hypocortisolism
The following are potential HPI questions for hypocortisolism (low cortisol):
- What are the patient's symptoms, such as fatigue, weight loss, or skin changes? 2
- Has the patient experienced any stressful events or chronic stress? 3
- Are there any signs of adrenal insufficiency, such as hypotension or electrolyte imbalances? 2, 4
- Has the patient been diagnosed with any underlying conditions, such as Addison's disease or pituitary disorders? 2
- What is the patient's medication history, including any glucocorticoid use? 2
Diagnostic Considerations
When evaluating a patient for hypocortisolism, consider the following:
- Measurement of plasma cortisol levels, including morning cortisol and response to ACTH stimulation 2
- Assessment of adrenal function, including UFC measurement and response to high-dose Dex suppression test 2
- Evaluation of pituitary function, including plasma ACTH measurement and response to corticotropin-releasing hormone injection test 2
- Consideration of other potential causes of hypocortisolism, such as chronic stress or critical illness 4, 3
Digital Tools for HPI Collection
Digital tools can be used to collect HPI information from patients, including: