Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Hypotension (low blood pressure) requiring vasopressors (medications to raise blood pressure)
Fatigue
Lethargy
Nausea or vomiting
Hypoglycemia (low blood sugar)
II. History of Present Illness:
Underlying critical illness (sepsis, trauma, major surgery, ARDS) – specify the illness
Duration of critical illness and hospitalization
Use of corticosteroids for the critical illness (type, dose, duration)
Onset and progression of symptoms suggestive of adrenal insufficiency
III. Past Medical History:
Previous diagnosis of adrenal insufficiency (primary or secondary)
Other medical conditions (diabetes, chronic kidney disease)
IV. Medications:
Current medications (including corticosteroids, vasopressors, insulin)
V. Vital Signs:
Blood pressure (BP) – hypotension despite vasopressors may suggest adrenal insufficiency
Heart rate (HR)
Respiratory rate (RR)
Temperature (Temp)
VI. Physical Exam:
General appearance (illness severity, signs of dehydration)
Skin pigmentation (hyperpigmentation may be a clue in primary adrenal insufficiency)
VII. Laboratory Studies:
Electrolytes:
Hyponatremia (low sodium)
Hyperkalemia (high potassium)
Blood glucose: may be low (hypoglycemia)
Cortisol level:
Baseline morning cortisol level (may not be reliable during critical illness)
ACTH stimulation test (gold standard for diagnosis but may be contraindicated in critically ill patients)
Random cortisol level with cosyntropin (ACTH) stimulation: may be used if ACTH stimulation test is not feasible
VIII. Assessment:
Suspected critical illness-related corticosteroid insufficiency (CIRCI) based on clinical presentation (hypotension, fatigue, nausea) following corticosteroid use for critical illness.
Severity of CIRCI
Limited reliability of cortisol testing in the critical illness setting
IX. Plan:
Hydrocortisone replacement therapy: Empiric low-dose hydrocortisone therapy should be initiated while awaiting confirmatory testing (if feasible) due to the high mortality associated with untreated CIRCI.
Dose adjustment based on clinical response and hemodynamic status.
Weaning from vasopressor support as tolerated with adequate cortisol replacement.
Cortisol level with cosyntropin stimulation test may be attempted later during recovery to confirm diagnosis (if contraindicated initially).
X. Prognosis:
Discuss the potential for improvement with appropriate corticosteroid replacement therapy.
Prognosis depends on the severity of the underlying critical illness and response to treatment.
XI. Notes:
Include any additional observations or concerns, such as patient’s response to treatment, communication with the team managing the critical illness, and the need for endocrinology consultation.
XII. Resources:
Consider providing patient education materials on adrenal insufficiency from reputable sources (e.g., American College of Endocrinology, National Adrenal Diseases Foundation).
XIII. Disclaimer:
This template provides a general framework for a critical illness-related corticosteroid insufficiency progress note. The specific content of the note will vary depending on the individual patient, the underlying illness, and the available diagnostic tests. Early recognition and treatment of CIRCI are crucial for improving outcomes in critically ill patients.