A 45-year-old with known Addison's presents with vomiting, hypotension and confusion. How would you manage her?

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This presentation is highly suggestive of adrenal crisis, a medical emergency. ABCDE assessment and immediate treatment without delay: IV hydrocortisone 100 mg stat then 50 mg every 6 hours or a 200 mg/24h infusion. Simultaneously start aggressive 0.9% saline resuscitation, adding dextrose if hypoglycaemic. Treatment should not be delayed for results, but I would send urgent cortisol, ACTH, U&Es, glucose and cultures, as intercurrent infection is a common precipitant. Monitor BP, urine output, electrolytes — particularly Na/K — and glucose. Once stabilised, identify the trigger. Before discharge ensure clear sick-day rules, an emergency hydrocortisone injection kit, education on when to seek urgent care, and a steroid emergency card or medical alert. Fludrocortisone is not required acutely as high-dose IV hydrocortisone provides sufficient mineralocorticoid activity; it can be reintroduced once back on physiological replacement.

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