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Life Threatening? No
Write-up: Autoimmune adrenal insufficiency. Dx: Aug 08. Several months severe fatigue, myalgia. 9/12/08 Reviewed endocrinologist medical records of 6/10-8/18/08. FINAL DX: adrenal insufficiency Records reveal patient experienced episodes of excessive fatigue beginning 2/2007 which progressed. Included dizziness, lightheadedness, overheated with activities, pale, hair loss, nausea, diarrhea for 2 mos, weight loss. Was on oral contraception which was d/c 6/08. 9/16/08 Reviewed ER medical records of 2/20/07 & 9/12/07. 2/20/07 Final ER Dx: gastroenteritis w/mild dehydration Records reveal patient exprienced N/V/D, chills & abdominal discomfort x 24 hours. Tx w/IVF & antiemetics. Responded well & d/c to home. LABS: UA WNL. 9/12/07 Final ER Dx: sore throat secondary to mononucleosis Records reveal patient recently dx w/mono had increasing throat swelling & difficulty breathing, decreased appetite, nausea, difficulty swallowing, abdominal pain, slight SOB. Exam revealed enlarged & red tonsils, cervical lymph node enlargement. Tx w/steroids & pain meds. D/C to home. 9/19/08 Reviewed PCP medical records of 10/3/07-8/5/08. FINAL DX: adrenal insufficiency, hypothyroidism, ADHD, anxiety/depression, OCD. Records reveal patient experienced anxiety/depression, OCD, fatigue, lower abdominal pain & fever when see 10/07. Only able to attend school for 1/2 days. Referred to neuro & admitted 10/26/07 for questionable seizure, w/u neg. Had shotty cervical nodes bilaterally. 1/2008 referred to rheumatologist. Hosp d/c summary, neuro consult, eye exam, rheum consult, sleep center consult, endocrine, psychiatric consult all included. D/C summary of 10/26-10/29/2007 states final dx: anxiety, depression, s/p inf mono. LP done. Had episodes of staring & RLE shaking. Neuro exam revealed asthenia, slow mentation, HA, possible seizures, ankle clonus. Rheum consult for chronic fatigue, recurrent mouth sores, joint aches/pains & muscle aches/pains. 1/26/2010 Follow-up: Adreral Insufficieny-which will be lifelong.
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