When Stress Is Not the Only Culprit: A Case of Secondary Adrenal Insufficiency in a Young Patient With Graves' Disease.

This case report underscores the significance of maintaining a broad list of differential diagnoses, including adrenal insufficiency, when evaluating patients who present with recurring episodes of hypotension and generalized fatigue. It further underscores that T3 thyrotoxicosis can manifest as the initial and sole presenting feature of Graves' disease. Finally, it emphasizes the critical importance of employing a multidisciplinary approach to discharge high-risk patients from the hospital to minimize the risk of acute decompensation.

Tachy-Brady Syndrome in a Schizophrenic Patient: A Case Report.

Tachy-brady syndrome is the result of sinus node dysfunction (SND), an electrocardiographic phenomenon caused by defective pacemaker functioning that leads to alternating arrhythmias. We present a case of a 73-year-old male with multiple mental health and medical comorbidities who was admitted to the inpatient floor for catatonia, paranoid delusions, refusal to eat, inability to cooperate with activities of daily life, and generalized weakness. Upon admission, a 12-lead electrocardiogram (ECG) showed an episode of atrial fibrillation with a ventricular rate of 64 beats per minute (bpm). During hospitalization, telemetry recorded a variety of arrhythmias such as ventricular bigeminy, atrial fibrillation, supraventricular tachycardia (SVT), multifocal atrial contractions, and sinus bradycardia. Each episode spontaneously reverted and the patient remained asymptomatic throughout these arrhythmic changes. These frequently fluctuating arrhythmias on resting ECG confirmed the diagnosis of tachycardia-bradycardia syndrome, also known as tachy-brady syndrome. Medical intervention, especially for cardiac arrhythmias, in patients with paranoid and catatonic schizophrenia can be challenging, as they might not share their symptoms. Additionally, certain psychotropic medications can also cause cardiac arrhythmias and must be carefully evaluated. The decision was made to start the patient on a beta-blocker and direct oral anticoagulation for reducing the risk of thromboembolic events. Due to an unsatisfactory response to drug therapy alone, the patient qualified as a candidate for definitive treatment with an implantable dual-chamber pacemaker. Our patient had a dual-chamber pacemaker implanted to prevent bradyarrhythmias and continued oral beta-blockers to prevent tachyarrhythmias.