Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, Atrial fibrillation, Azotaemia, Blood alkaline phosphatase increased, Blood creatinine increased
Clinical narrative: 77YM admit with Malaise, chills, myalgias, diarrhea on admission possibly secondary to COVID vaccine vs uremia.  chief complaint of body aches, chills, shortness of breath, weakness, diaphoresis with low blood sugar for approximately 1 week after getting the Johnson & Johnson Covid vaccine.  He did stop taking his Lantus at that time.  In the emergency room he was found to have creatinine 3.5, troponin elevated 0.3 and BNP of 13,000.  He was Covid negative, his chest x-ray did show interstitial pulmonary edema with cardiomegaly.  Patient was admitted for advancing and chronic kidney disease stage V patient initially was started on hemodialysis however his renal function did improve so dialysis was stopped.  He was initially on empiric antibiotics for 48 hours however this was stopped due to no evidence of infection.  His he was found to have a sodium of 134, however this did decrease during his admission down to 119 on 4/23.  He has been  improving however very slowly throughout his stay here w/ nephrology managing patient's hyponatremia.  Patient was started on tolvaptan however this was discontinued on 4/27.  His sodium did improve. to 128 prior to discharge.  His Lasix was restarted however his metolazone was stopped.  His Metformin also was discontinued indefinitely secondary to his chronic kidney disease. In regards to his fever, chills, malaise, myalgias and diarrhea that resolved upon admission.  Patient  DISHCARGED home    #Malaise, chills, myalgias, diarrhea on admission resolved possibly secondary to COVID vaccine vs uremia  -Uremia improved.  -Blood cx final Neg - Hepatitis B antibody and antigen negative, hepatitis C antibody negative, respiratory panel negative  #Severe Hyponatremia - improved to 127 on discharge. -Has required Tolvaptan, however d/c on 4/27 as Na improved. Discussed w/ nephrology, will restart Lasix.  -f/u outpatient w/ CMP within 1 week of discharge -Metalazone held  #AKI (improved) on CKD -due to diabetic nephropathy, hypertensive sclerosis.  - initially it was thought patient had developed end-stage renal disease given degree of uremia so a tunneled dialysis catheter was placed and he was initiated on dialysis.  However since starting dialysis his renal function has improved.  He is now making about a liter of urine a day,  his creatinine has returned to his baseline and has been  stable since his last dialysis session.  Nephrology feels likely he had some acute kidney injury which has now resolved, possibly due to to his presenting constellation of symptoms of chills myalgias and diarrhea.  Nephrology feels he does not need HD at this time.  He does have a history of significant proteinuria and likely will need dialysis in the future but at this time given the fact that his renal function is stable he  is able to forego this for now.  He lives a significant distance from the closest dialysis center so this would be preferential for him and when he does need dialysis, nephrology is going to work on arranging PD when his GFR<20   - TDC removed 4/21 . At discharge Cr improved below baseline  #Uremia improved w/ HD  #CAD s/p CABG in 2017, w/ Cardiomegaly  -Medical management for cardiomyopathy. Continue BB. No ACE-I due to renal function. Could use Hydralazine/Isosorbide for after load reduction. F/u appointment scheduled w/ cardiology.  -BP Currently 120-140's Will monitor as has been improving.  #sCHF w/ EF 35-40% not in acute exacerbation  -Lasix, management as above -Metoprolol. Unable to be on ACE/ARB 2/2 to CKD #Paroxysmal afib  - Currently in sinus  - continue home metoprolol & Apixaban     #Diabetes mellitus  Type 2 with recent symptomatic hypoglycemia- Well controlled HgA1c 5.8 -Indefinitely hold Metformin    #Chronic hypoxemic respiratory failure Secondary to COPD.  - On 2-3L NC at home x 3-4 years although pt takes it off when he goes out.  At baseline or improved - on 0.5-1L NC here, briefly on room air 4/25  -continue bronchodilators    #Elevated transaminases/alk phos  - suspect due to hepatic congestion as well as mineral bone disease from renal dz  -  US abdomen remarkable only  for multiple small gallstones and small ascites.   #Anemia of chronic disease 2/2 to CKD  -  Epogen with HD.   -stable on discharge