Correct!

5. All of the above

For unexplained hypotension and mental status changes, looking for sepsis, infection, and myocardial ischemia or cardiomyopathy is appropriate. Because hypothyroidism can also cause obtundation and many of her presenting symptoms, this should be pursued.  Blood cultures were sent, BNP level returned at 306 (normal range).  An echocardiogram demonstrated normal LV ejection fraction, diastolic dysfunction, and the absence of valvular disease or an effusion. Her TSH level returned at 0.62 µIU/mL, within the normal laboratory range.  A random cortisol level returned at <1.0 µg/dL.

What would you do next? 

1. ACTH stimulation test
2. Check thyroxine (T4) level
3. Treat with IV normal saline
4. 1 and 3
5. All of the above

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