Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Syncope, Therapy change, Thyroxine normal, Troponin increased, Unresponsive to stimuli
Clinical narrative: Patient is a 71 y.o. male patient of, MD with history of panhypopituitarism, secondary to craniopharyngioma that was surgically removed 1997, CAD s/p stenting, T2DM, CKD3, and hypothyroidism who presented to facility on 9/20/23 following episode of unresponsiveness,Pt found minimal responsive on toilet by spouse. Pt agonal breathing and required NRB per EMS. Progressive improvement following supportive measures upon ED arrival. No trauma reported. No falls. Reportedly patient not feeling well for few weeks. Tested positive for COVID this admission. Admitted to ICU for lactic acidosis and hypotension, both of which have resolved with fluid administration. ID had seen patient and signed off. Patient was also seen by nephrology and endocrinology for panhypopituitarism.  Patient had labile blood sugars that are much lower this day.   Discussed with Dr. prior to discharge with endocrinology, he is recommended to hold long-acting insulin and short-acting insulin at discharge.  Prednisone home dose 5 mg was advised to be increased to 15 mg for 5 days, this was due to some concerns of mild adrenal insufficiency,patient was instructed that if his blood sugars are greater than 180 to call his primary care physician as well as his endocrinologist for further guidance on resuming his insulin.  Patient's oral intake was poor while in the hospital, most likely contributed to his hypoglycemia.  He will need close monitoring and follow-up to resume his insulin patient verbalized understanding.Endocrinology team okay with discharge.  Nephrologist is recommended to continue DDAVP at discharged.  Patient medically stable and discharged home with HHC.     DM 2, now with hypoglycemia Home: Metformin, Trulicity and basalgar 40 u, lispro 20 u q ac,   A1c 7.6 Metformin and trulicity stopped, was on lantus and SSI Long-acting insulin was decreased to 20 units, and pre-meal 7u- both discontinued as pt has required dextrose gel his AM, qill request endocrinology consultation due to labile blood sugars.  Hold off long-acting insulin dose monitor sugars for now due to significant lows, await endocrine input Acute metabolic encephalopathy Panhypopituitarism secondary to craniopharyngioma Presumably orthostatic syncope in the setting of poor intake, dehydration Afebrile, HR 55, SBP low Pt was not able to take medications due to COVID infection Echo 9/20 normal LV fn, EF~60%, CTPA neg PE, chronic interstitial lung disease  IVF resuscitation continued, restarted DDAVP, prednisone Encephalopathy has resolved, MS back to baseline PT / OT: 5-7 d w hopeful progression Keep until further PT / OT, CM consulted for discharge needs,has not been ambulating here   Atypical chest/epigastric pain, appears to be related to gastritis, on prednisone vs musculoskeletal Ekg repeated today shows RBBB without new ST changes Start pantoprazole and add maalox 4x daily, may be contributing to poor oral intake    Metabolic acidosis Lactic acidosis Lactic acid 10.1>1.3, secondary to dehydration,improved after IVF   Sepsis due to COVID infection  Transaminitis Reports URI symptoms and diarrhea for 1 day, no fevers or shortness of breath Met sepsis crieria, Sepsis was present on admission and continues to be treated Consulted infectious disease, continued recommendations appreciated Continue home dose steroids, started on Remdesivir ID consulted,  AST 110->633, ALT 43->176, ? Related to remdesivir Due to improvement in COVID and hemodynamics ID has cleared pt for discharge AKI on CKD 3 Hyponatremia Hypokalemia Hypomagnesemia Scr on admission 2.62 (baseline ~ 1.3), Na 128, on DDAVP AKI due to dehydration, IV contrast, hypotension Nephrology consulted to assist w both K low again 3.2-replace 60meq , replace mag    Abnormal CT head History of panhypopituitarism secondary to craniopharyngioma Follows with neuro-ophthalmology and endocrinology   Per chart review, he had surgery for craniopharyngioma via right frontal craniotomy in 1997 at facility with Dr., Home regimen: prednisone 5 mg daily, levothyroxine 175 mcg desmopressin 0.1 twice daily, not on testosterone replacement CT head 9/20 shows mass centered in the suprasellar region perched, could relate to residual neoplasia or postoperative change related to prior tumor resection, possible ecchordosis physaliphora.  Clinically neurological function intact, continue outpatient follow-up with facility MRI brain pending    Abnormal CT Lung nodule Per chart review, quit smoking about 27 years ago, started smoking 52 years ago, approximately 30-pack-year smoking history surveillance for 3x5 noncalcified nodule of the right lower lobe, outpatient follow-up   History of hypothyroidism Secondary to above, TSH <0.01 T4 1.4, continue home synthroid   History of CAD No chest pain or shortness of breath LHC 9/2022: extensive CAD with stable collaterals. No intervention.  Continue home aspirin, atorvastatin, Plavix Elevated troponin Troponin 77>85 (10%) no reported chest pain or dyspnea Likely 2/2 demand ischemia Echo 9/20 normal LV fn, EF~60%, no further w/u needed