Age: 63.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Fatigue, Granuloma, Hyponatraemia, Hypophagia
Clinical narrative: Date of Admission Admit Date: Jun-13-2022  Date of Discharge Date of discharge Jun-17-2022  Allergies Aspirin - Stomach problems  Chief Complaint Shortness of breath, weakness  Final Diagnoses Acute COVID-19  resolved  Hyponatremia Resolved Jun-17-2022  chronic  Malignant tumor of breast  Chronic obstructive lung disease  Procedure(s) Performed None  Lab Results Jun-17-2022 1120 Chemistry OSMO-U  199 Jun-17-2022 0440 Chemistry NA  128OSMO  257.3 Jun-17-2022 0030 Chemistry NA  127OSMO  256.5 Jun-16-2022 2040 Chemistry NA  126OSMO  252.9OSMO-U  408 Jun-16-2022 1600 Chemistry NA  125OSMO  250.1 Jun-16-2022 1330 Chemistry NA  127OSMO  256.0 Jun-16-2022 0850 Chemistry NA  128OSMO  258.3 Jun-16-2022 0445 Chemistry NA  127OSMO  253.5 Jun-16-2022 0045 Chemistry NA  127OSMO  253.1 Jun-15-2022 2050 Chemistry NA  124OSMO  248.7 Jun-15-2022 1655 Chemistry NA  123OSMO  246.8 Jun-15-2022 1250 Chemistry NA  123OSMO  246.9 Jun-15-2022 0610 Chemistry NA  122OSMO  242.9 Jun-15-2022 0225 Chemistry NA  120OSMO  239.2 Jun-14-2022 2210 Chemistry NA  119OSMO  237.3 Jun-14-2022 1800 Chemistry NA  118OSMO  240.5 Jun-14-2022 1331 Chemistry NA  116OSMO  234.0 Jun-14-2022 0900 Chemistry NA  118OSMO  236.1 Jun-14-2022 0403 Chemistry NA  118OSMO  237.2 Jun-13-2022 2300 Chemistry NA  113OSMO  228.3 Jun-13-2022 1745 Chemistry NA  115OSMO  231.8 Jun-13-2022 1716 Chemistry NA  113OSMO-U  89 Jun-13-2022 1430 Serology COVID  Pos Jun-13-2022 1430 Chemistry NA  113OSMO  228.3 Imaging Results Chest radiograph 06/13/2022  "DISCUSSION: Right port stable. Hyperinflation with bronchial wall thickening and chronic appearing coarsening of the interstitium. Strandy bibasilar lung opacities likely atelectasis/scar or inflammatory disease. No pleural effusion or pneumothorax. ASVD and borderline cardiomegaly. Old granulomatous disease. IMPRESSION: 1. As described above."  Functional Status* No Functional Impairments  Mental Status* Normal Cognition  Social History tobacco use Former Smoker, 1 Packs Per Day, Ended Jun-14-2021, Smoking Cessation No  alcohol use No Known Use  marital status Unknown  occupation Waitress  general comment Was at nursing home until approximately 1 week ago for rehab, currently lives with brother  Health Concerns Acute COVID-19  Hyponatremia  Chronic obstructive lung disease  Malignant tumor of breast  Former Smoker, 1 Packs Per Day  Father Deceased Diabetes mellitus; Chronic obstructive lung disease; Alpha-1-antitrypsin deficiency  Mother Deceased Congestive heart failure @ 88 Essential hypertension  Sister Deceased Alpha-1-antitrypsin deficiency  Vital Signs Jun-17-2022 0730 T 97.5 HR 84 RR     27 BP   127 /     42  O2Sat 97 Jun-17-2022 0504 T 98.1 Jun-17-2022 0416 HR 69 RR 15 BP   106 /     52  O2Sat 98 PHYSICAL EXAM CONSTITUTIONAL: Patient is an acutely and chronically ill-appearing 63-year-old female who appears older than stated age. She is calm and in no distress.  EYES: Anicteric sclera with no discharge noted. Pupils equally round bilaterally.  CARDIOVASCULAR: Heart rate and rhythm are regular with no murmurs on auscultation. Pulses 2+ in bilateral radial and dorsalis pedis arteries. No peripheral edema noted.  RESPIRATORY: Patient is on 3 L supplemental O2 via nasal cannula. No conversational dyspnea, which is greatly improved from admission. Breath sounds present and equal in bilateral anterior lung fields. Wheezing is improved from yesterday.  GASTROINTESTINAL: Abdomen is flat, soft, nontender, and nondistended. Bowel sounds present and normoactive.  MUSCULOSKELETAL: Patient is ambulatory with minimal assistance. Gait is appropriate. Strength is greatly improved from admission.  PSYCHIATRIC: Patient is alert and oriented to person, place, time and situation. She is able to answer questions appropriately. Mood and affect are appropriate. She is pleasant and conversant.  Hospital Course Patient is a 63-year-old female with a past medical history of stage III lobular breast cancer s/p bilateral mastectomy, port placement, and 1 round of chemotherapy with paclitaxil. Other PMH can not for COPD on 3 L went oxygen at baseline, previous tobacco dependence, and depression. She presents to the ER on 06/13/22 with worsening shortness of breath, cough, weakness, fatigue, and decreased po intake. On the evening of 06/08/22 patient had a positive home covid test. She is being admitted to the Internal Medicine Service for ongoing evaluation management of chronic hyponatremia and COVID-19 infection. Her total hospitalization was 5 days.  6/14/22 On admission yesterday, patient was started on DDAVP using the clamp meth id as well as intermittent bolusing of 3% saline. Q4hr BMP's are being performed to monitor sodium rise regularly. There were no acute events overnight and sodium is improving at an appropriate rate. This morning patient is awake and in bed. States she feels a little bit better than yesterday but her headache is back. She states that the Tylenol has not helped but the Depakote she received IV yesterday resolved her headache for a few hours. She also reports a stuffy nose. Shortness of breath, per patient, has improved as well.  06/15/2022 There were no acute events overnight. Patient tells me that she continues to feel better with increasing strength. She reports that her appetite is improving but still not back to baseline. She tells me that she slept well last night and seems encouraged when I tell her that her sodium is improving at an appropriate rate.  6/16/22 There were no acute events overnight. When I enter the room this morning she is ambulating with physical therapy. She is in good spirits and is hopeful that she will go home tomorrow. She reports that her strength, appetite, and energy have been improving. She also asks if we will be able to get the MRI prior to discharge.  6/17/22 On day of discharge Patient is looking significantly improved from admission shortness of breath has resolved and strength has improved. She is fit for discharge today with close follow-up with her oncologist and primary care. Sodium on morning of discharge is noted to be 128, after stopping desmopressin and 3% saline.  Condition at Discharge Stable  Discharge Medications Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 PUF INHALATION EVERY 4 HOURS AS NEEDED for SHORTNESS OF BREATH - WHEEZING Amitriptyline HCl Oral Tablet 10 MG 10 MG ORALLY DAILY AT BEDTIME amLODIPine BESYLATE 10 MG ORALLY DAILY AT BEDTIME (ePrescribed on Jun-17-2022 1149) Budesonide Inhalation Suspension 0.5 MG/2ML 1 EA NEBULIZED INHALATION TWICE DAILY Dexamethasone Oral Tablet 4 MG 20 MG ORALLY ONCE A DAY LISINOPRIL 20 MG ORALLY ONCE A DAY (ePrescribed on Jun-17-2022 1151) LORazepam Oral Tablet 1 MG 1 MG ORALLY 3 TIMES A DAY AS NEEDED for ANXIETY OLANZapine Oral Tablet 2.5 MG 2.5 MG ORALLY DAILY AT BEDTIME Ondansetron HCl Oral Tablet 4 MG 4 MG ORALLY EVERY 6 HOURS AS NEEDED for NAUSEA/VOMITING Paxlovid Oral Tablet Therapy Pack 20 x 150 MG & 10 x 100MG 1 UNT ORALLY TWICE DAILY Perforomist Inhalation Nebulization Solution 20 MCG/2ML 1 EA NEBULIZED INHALATION TWICE DAILY RisperDAL Oral Tablet 0.5 MG 0.5 MG ORALLY DAILY AT BEDTIME Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Continue taking same as home Yupelri Inhalation Solution 175 MCG/3ML 1 EA NEBULIZED INHALATION ONCE A DAY Discharge Disposition Discharge to home  Plan Assessment: - Chronic hyponatremia, symptomatic, mutlifactorial secondary to decreased po intake and chronic HCTZ use Na 113 on admission, baseline 130, resolved -COVID-19 infection, incidental -Stage III lobular breast carcinoma status post bilateral mastectomy and sentinel lymph node biopsy. - COPD, per history - Chronic hypoxic respiratory failure, requiring 3 L supplemental oxygen via nasal cannula. -Previous tobacco dependence   Plan: Patient is stable and fit for discharge home this morning. Sodium has improved to 128 this morning and has remained stable since discontinuing DDAVP and 3% saline yesterday.  Follow-up: She is already scheduled with Dr. for follow-up on Thursday 6/23/2022 with CBC, BMP, and DDAC labs ordered. Per request of Dr. we have ordered an MRI brain to be done outpatient to evaluate for possible metastasis which could have contributed to her hyponatremia.  She is scheduled to follow-up with her PCP, NP on Friday 06/24/2022 at 10:00 a.m..  Today is day 10 after symptom onset regarding her COVID-19 positive status. After today patient will no longer need to quarantine.  DO  Primary Care Provider NP  Electronically signed on Jun-17-2022 1311 I have seen and physically examined the patient on 6/17/2022 and agree with the documentation of Dr. I have also discussed my findings and plan of care with Dr. Any changes and additional information are listed below.  Patient in good spirits and excited to be discharged. Explained our discharge recommendations of continuing 1500 cc fluid restriction. If she starts feeling lightheaded or feels unsteady on her feet she needs to be evaluated. Was going to order an outpatient BMP for next week to make sure she remains stable in her home environment from a sodium perspective but she already has outpatient labs that include electrolytes scheduled for her appointment with Dr., confirmed with the clinic. I have written an order for an outpatient MRI to evaluate for possible metastatic disease with results to be CC'd to Dr. for review. Centralized Scheduling to schedule with patient. Patient to complete course of paxlovid for the completion of 5 days. She has shown no signs of disease progression which is encouraging and in fact she should be out of isolation status by the end of the weekend. Follow up with PCP in 1 week. follow up with Oncology on Thursday at scheduled appointment. We have written for single drug lisinopril to replace her HCTZ as well as amlodipine at HS as she responded well to starting that to maintain normotension.  44 minutes spent coordinating dishcarge Electronically signed by DO on Jun-18-2022 1853