Published 9 March 2009, doi:10.1136/bmj.b868
Cite this as: BMJ 2009;338:b868

Practice

Commentary: Managing clinician’s assessment

¹ Hospital Clinico San Carlos, Madrid 28040, Spain

doi:10.1136/bmj.b6doi:10.1136/bmj.b246doi:10.1136/bmj.b247doi:10.1136/bmj.b799doi:10.1136/bmj.b796doi:10.1136/bmj.b846doi:10.1136/bmj.b867

The first 150 words of the full text of this article appear below.

Doctors from different countries have engaged in a stimulating debate around Mrs Barroso’s case. When Mrs Barroso presented to the emergency room, her haemodynamic stability was restored after a steroid bolus, clearly pointing to adrenal gland involvement, and we agree with most of the respondents on bmj.com that acute adrenal insufficiency was the likely diagnosis at presentation.¹ Unfortunately, rapid measurement of serum cortisol and adrenocorticotropic hormone was not available at our laboratory at the time. Her dramatic and progressive haemodynamic deterioration demanded a prompt therapeutic decision, and we administered steroids even though other data such as the normal electrolyte concentrations, normoglycaemia, and absence of previous steroid use did not support this diagnosis. Other suggested aetiologies such as sepsis, ectopic pregnancy, or staphylococcal toxic shock would be unlikely given Mrs Barroso’s normal full blood count, transvaginal and abdominal ultrasound appearances, and complete recovery after the steroid bolus. As Gamal Alfitori . . . [Full text of this article]

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