Age: 77.0
Sex: F
Vaccine: COVID19-2
Symptoms: Hypotonia, Immobile, Inappropriate antidiuretic hormone secretion, Intramedullary rod insertion, Laboratory test
Clinical narrative: Patient is a 77 y.o. female who presented from home on 12/19/2022 with after a mechanical fall resulting in left femur fracture. She underwent IM nailing of the left hip on 12/20/22 with Dr. The patient tested positive for SARS-CoV-2 and discharge to SNF subsequently cancelled on 12/26.  Clinical course complicated by hyponatremia, urine studies suggestive of SIADH. Nephrology was involved with care.  Serum sodium levels improved after receiving tolvaptan, now stabilized.     Left intertrochanteric femur fracture Mechanical fall -Presenting after falling at home after losing balance.  Reports balance issues at baseline and uses a cane normally to ambulate. -X-ray left hip reveals acute fracture of proximal left femur with varus angulation -Orthopedics following. S/p intramedullary nailing of left hip with Dr. on 12/20/22.  We will follow-up with orthopedic in the outpatient setting. -Pain remains well controlled   COVID-19 No longer symptomatic.  SARS-CoV-2 negative on admission. Positive on 12/26.  +Cough (onset: 12/22 or 12/23), diarrhea -CXR on 12/27/22: Consolidative change in the left lung base and right infrahilar region suggests atelectasis or pneumonia. -COVID vaccinated and boosted. Last booster 9/7/22 -Not requiring supplemental oxygen thus no COVID specific therapies initiated -ID e-consulted. Paxlovid initiated on 12/27. Statin held during this time, will resume on discharge   Hypotonic hyponatremia Na+ 123 on 12/28 AM labs Urine osmolality and urine Na+ on 12/28/22 consistent with SIADH Serum cortisol 18 ruling out AI TSH was low; Synthroid dose increased this admission -Encouraged increase in solute intake -Nephrology consulted.  Initiated tolvaptan.  Appreciate assistance and their final recommendations.  Plan for discharge to facility when safe from a nephrology standpoint.  Would recommend recheck of serum sodium levels in the next 2-3 days.   Diarrhea Improving.  Suspect secondary to COVID-19 vs side effect of Paxlovid -Stool C.diff PCR negative on 12/28 -PRN imodium utilized during this hospitalization   Age-related osteoporosis with pathologic fracture Patient presented with a femur fracture. Patient does not have an existing diagnosis of osteoporosis. Labs:             25 OH Vitamin D level 61             Corrected Serum Calcium level  9.6             TSH 0.18 Patient has no contraindications to starting bisphosphonate treatment  Recommend initiation of bisphosphonate therapy after discharge from SNF when functional status improved. Adjusted home dose of levothyroxine due to low TSH. Acute postop anemia Likely due to blood loss from recent fracture, surgery, and dilutional effect from IV fluids -Hgb 6.8 from 10.9. Received 1 unit PRBC on 12/20 -Hgb 7.7 as of 12/22. Repeat CBC on 12/25 showed worsening anemia again with hgb 6.8. Additional 1 unit PRBC given  -Hemoglobin has been stable, monitor intermittently.   Hypotension, improved -likely due to anemia and recent surgery -improved with blood products and IV fluids -BP has been stable   Postop urinary retention -related to immobility and pain -required straight cath over night with 1000 cc output -Foley placed 12/24.  Still having difficulty with mobility.  Patient and family would prefer to have this remain in.  They will have this issue readdressed at the facility.  Would consider trial of void as mobility improves.