Date of office visit: 4/22/2021 2:15 PM  Intake done by: LPN Reason for today's visit: New Patient 30 minutes HR: 80, regular rate & rhythm   BP: 136/78 (prehypertension)    weight: 195 lbs  88.6 kg    temperature: 98.5 F height: 5 ft 6 inch (measured) body mass index: 31.5 Obesity Classification: Class I, Simple obesity   Progress Note xxxxx 4/22/2021  Patient is a 43-year-old female referred to me for management of hemorrhage into her pituitary gland.  February 9, 2021  11 AM she received Moderna vaccine. by 7 PM she had a severe headache, leg numbness, severe arthralgias in her knees, global paresthesias, pressure behind her eyes, she describes her head is very heavy and pressurized was very painful.   Symptoms lasted for three days and gradually remitted. To a lesser degree  the headache persisted longer but resolved  March 10, 2021  received Moderna vaccine. On same day she developed headache, chest pain, back pain, leg numbness. She states that when she walked it exacerbated chest pain and headache and she had to walk very gently on her toes. She tried Tylenol, ibuprofen without effect. The symptoms persisted. She started taking two aspirin a day.  March 14 she worked third shift as usual (despite symptoms)  March 15, the symptoms were bad enough that she felt she had to go to the emergency room.  March 15, 2021 18:56      CT Head or Brain C-:    7 mm rounded hyperdensity within the pituitary gland which may represent a hyperdense pituitary mass lesion.    Associated hemorrhage is not excluded.   March 15, 2021 22:34   MRI Brain C-/C+:    There is 0.6 x 0.6 x 0.7 cm round structure in the anterior pituitary gland with high T1 signal, dark T2 signal, susceptibility artifact and no enhancement.    This likely represents a hemorrhage within the microadenoma.    Advise neurosurgical consult and follow-up MRI in 6 months. ________________  3/17/2021 I was consulted (while she was in hospital, chart review only. Patient not seen at that time)   I wrote...  PITUITARY ACTH Patient had ACTH stimulation test yesterday. Assuming she has received no steroid Rx during this admission prior to the ACTH stimulation test (as I have been told), then these results confirm that her adrenal gland has the ability to respond to ACTH and thus there is no reason to believe the underlying pituitary abnormality had resulted in chronic ACTH deficiency from the pituitary lesion that resulted in hemorrhage.  3/16/2021 4:32 PM   .Cort 30 min Stim   Cortisol 30 Minutes Post ACTH      19.3         mcg/dL   Cortisol 60 Min                    27.6         mcg/dL            As the pituitary hemorrhage was an acute event, it is possible the pituitary currently does not have the ability to make adequate amounts of ACTH, despite the normal ACTH stim test, but the situation is too acute to cause the adrenal to atrophy (as a result of chronic ACTH deficiency) and she still could have secondary adrenal insufficiency. When there is a chronic ACTH deficiency of sufficient duration, the adrenal gland will eventually atrophy and the patient will then develop primary adrenal insufficiency as well and then the ACTH stim test will become abnormal.  As we do not know if her pituitary can make ACTH appropriately, I think it would be prudent to treat the patient with PREDNISONE 2.5 mg qAM for now even thought we do not know for certain whether her pituitary can make ACTH. After discharge, she should be evaluated by endocrine to assess for ACTH deficiency. She should be advised to seek medical attention if she develops symptoms of adrenal insufficiency like nausea, emesis, abd pain, orthostatic symptoms.   PITUITARY TSH 3/15/2021 11:47 PM   T3 Total                      83         (normal: 60-181)  nGm/dL   T4, Total                     7.3        (normal: 4.5-13.3)  mcg/dL   TSH, 3rd gen                  2.160      (normal: 0.358-3.740)  mclU/ml  I think, based on above admission TFTs, she should also be treated with LEVOTHYROXINE 100 mcg qAM even though we do not know for certain if she has central hypothyroidism. This too should be reassessed in the future.   PITUITARY LH/FSH If she acutely or recently developed secondary amenorrhea and FSH is not c/w menopause, then that would suggest the lesion or hemorrhage has causes hypogonadotrophic hypogonadism. This situation would increase the probability she has central adrenal insufficiency and central hypothyroidism. If menses remains normal henceforth, the it is more likely her ability to make TSH and ACTH are normal.  _______________   Patient was discharged on levothyroxine 100 µg in the morning and prednisone 2.5 mg daily. She's also on iron pills.  Past medical history: Iron deficiency anemia. Treatment was an IUD, after which she's gained a lot of weight.  Medicines: IUD, Levothyroxine 100 mcg QAM, prednisone 2.5 mg QAM, ferrous sulfate 325 mg daily  Allergies: none  No cigarette use, alcohol abuse or drug use  Family social history: patient has three children. High school educated. Healthcare worker.  REVIEW OF SYSTEMS: overall health is good. She feels well. No headache.  No nausea. No nocturia  Physical exam:  Extraocular muscles intact.  VF full Lungs are clear.  Cardiac exam regular.  Impression: hemorrhage into pituitary gland  Temporarily, symptoms correlate with covid vaccination in a women who previously was (reportedly) dx with covid infection. Maybe the pituitary hemorrhage was the result of the coronavirus vaccination or the aspirin she was taking.   At this point she's feeling well. It's been about one month since the event. I'd like to wait another month and then proceed with testing of a pituitary gland to try to figure out if she really needs to remain on levothyroxine and prednisone and reimage the pituitary.  On the day of the testing she will take neither medicine in the morning. Will then measure LH, FSH, estradiol, TSH free T4 and cortisol and renal panel. Patient will then receive ACTH 0.25 mg IM and have cortisol measured at 30 minutes and 60 minutes. I will follow-up with her by phone.  She scheduled to see Dr. April 26. I would like to do another MRI but I would prefer to wait another month as she is clinically doing well and I want to allow the pituitary more time to "heal"/stabilize.  No follow-up is scheduled with me, if Dr. does not order an MRI and I will after I received next blood test.  M.D. 4/22/2021 3:40 PM Electronically signed by:  M.D. on 4/23/2021 2:47 PM