So it's clark with steven apps alpha 2 08851 8 2 year old gentleman jenny complained multiple falls at home and right hip pain with 2 weeks of productive cough macrophrolactinoma leading to panhypopituitarism known to doctor flanagan retinitis pigmentosa iron deficiency anemia 2023 cataract hypothyroidism gallbladder perforation 1996 cholecystectomy 1997 medications carbocetin 750 mg 3 times a day anoro ellipta 55 micrograms / 22 dry powder inhaler 1 dose per day famotidine 20 mg once in the morning fludrocortisone 100 micrograms in the morning loratadine 10 mg twice a day mirabegron modified release 50 mg in the morning paracetamol 1 g as required up to 4 times a day salbutamol 100 microgram inhaler 2 doses required senna 7.5 to 15 mg at night tamsulosin 400 micrograms modified release in the morning cabergoline which is c a b e r g o l I o d 500 microgram tablet once in the morning for prolactinemia finasteride 5 mg in the once in the morning hydrocortisone 10 mg in the morning and 5 mg at noon and 5 mg at night levothyroxine 100 micrograms well actually 200 micrograms in the morning spironolactone 25 microgram milligrams in the morning dexeril d3 1 tablet once a day 1000 units no known drug allergies to the past medical history copd most recent spirometry july 2022 fvc and fev 1 below low limit of normal fev 1 / fvc% above low limit of normal but below 70% possible mixed pattern of restriction + moderate obstruction some airway changes post bronchodilator obstructive sleep apnea severe with desaturation index of 53 per hour mild hypoventilation uses cpap at home she's in paroxysmal that's why it's so bad does it matter so we have to yeah she's not more acidic cells because if we want to call her what's the appetite yeah is she going to get infected that's the thing so what what investigations tsh undetectable free t 4 13.3 free t 3 awaited crp 94 with neutrophils 4.6 and white cells 5.8 anemic hemoglobin 120 with low red cell counts magnesium 0.69 sodium 122 with potassium 4.5 corrected calcium normal 2.11 most recent arterial blood gas ph 7.31 with c o 2 7.99 and p o 2 7.91 observations heart rate 62 90% respiratory rate 13 blood pressure 80 over 48 normal orientation good medical prognosis hello open your eyes for me hello sorry about that so hello how are you I'm fine I'm you feel okay yeah yeah yeah you feel fine do you know where you are at the moment oh yeah where are you where are we 1 minute there's some words clives open voice more spontaneously are you okay it's a p 3 0 I think we 2 pouches in the neck oh I'm 10 6 0 he's 6 15 his total defibrillation stopped a little bit than that so it's wet so mister atswell you've had some steroids which seems to have worked quite well you're a bit more awake for the now I think what's gone on is that you've had a you've got an exacerbation of your lung disease your copd bleeding which has affected your breathing slightly and then that's had a knock on effect onto your addison's disease which has caused an addisonian crisis it's a bit better now because you've had some steroids so that's improving that's good we still need to do a few things we need to keep you on a high dose of steroids we send a referral to the endocrinology team we need to get a history of your chest if you've not had 1 already and tinkle your oxygen saturations by dropping them to 88 to 92 we'll we'll help you cough and cough this stuff up and get a sample of it if we can is that alright yeah okay any questions for me are you weeing okay yeah I don't know who who do you live with at home mister rapps who who do you live with at home me me unfortunately for me that's not the case who it who do you live with okay and do you drink or smoke you do do you drink alcohol how much do you drink too much too much how much is too much and do you smoke you do how much do you smoke too much how good great well that was very informative what do you do for a living when did you last work with stress did you do okay great thanks we'll get a few bits and bobs sorted we'll carry on with these things and we'll see you soon okay so infection is exacerbation of copd infective with mild type 2 respiratory failure which is multifactorial secondary to adrenal insufficiency secondary to the acute illness, atrocnix steroids and panhypopituitarism the plan is to treat infective exacerbation of capd with with steroids and antibiotics continue intravenous steroids while critically unwell iv fluid replacement to improve blood pressure encourage to expectorate nebulized salbutamol and the protropium for 1 hour and repeat arterial blood gas in 1 hour's time to decide whether noninvasive ventilation required strict input output monitoring sputum culture endocrinology referral everything okay down there no good