Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Urinary retention, Urine osmolarity decreased, Urine sodium decreased, White blood cell count increased
Clinical narrative: Patient is a 89 y.o. male with a PMHx of paroxysmal atrial fibrillation (on Xarelto & propafenone), coronary artery disease s/p MI 2003 and 2009, hypertension, dyslipidemia, moderate obstructive sleep apnea, COPD, former tobacco use disorder, daily alcohol dependence was directly admitted to ICU for acute hypoxic respiratory failure secondary to COVID-19 infection, CAP, and bilateral pleural effusions. Complicated by hyponatremia, likely secondary to SIADH, which is resolving. Stable for transfer out of the ICU.    Acute respiratory failure with hypoxia COVID-19 PNA Pleural effusion only; CHF ruled out Leukocytosis of 13K. PCT wnl. Date of symptom onset: 10/1/2022 Date of COVID positive test: 10/4/2022 this was scanned into media tab on 10/16/22 Traveled to PRIVATE 9/19/22-10/11/22. Vaccination status: vaccinated and boosted Symptoms present on admission: Fevers, chills, shortness of breath, productive cough with yellow sputum CTPA no PE, bilateral pleural effusion, patchy irregular interstitial and groundglass infiltrates bilaterally, biapical parenchymal scarring with calcifications. Oxygen requirements: RA < 6 L nasal cannula Medical therapy: Dexamethasone 6 mg daily, he is beyond time frame for remdesivir ID following. On Pepcid 20 mg BID, Vitamin C 500 mg TID, Vit D 5000U Daily, Loratadine 10 mg Daily, Zinc 50 mg BID. Received one dose of tocilizumab 10/16 Follow up Sputum cultures - unable to collect. 1/2 blood Cx Staph Epi - appears to be a contaminant 2 D echo with EF 55-65% with LV segmental wall motion grossly normal and no pulmonary hypertension Continue Scheduled and as needed albuterol  On room air with oxygen sats above 92%   Acute on chronic hyponatremia Sodium on admission 110 Multifactorial, likely SIADH versus poor solute. Sodium correction 6-8 mEq/day Serum osmolality was 260 and urine osmolality 546 with urine Na 34  Liver US with normal liver echotexture. Nephrology following - Likely SIADH versus poor solute intake. Sodium up at 128, now seems to be trending down Started on salt tabs 1 g twice daily and continue fluid restriction Today at 124 < < 128 Given a dose of tolvaptan 7.5 mg Continue to monitor sodium levels.  Per nephrology if by tomorrow sodium > 130, can discharge on salt tabs with repeat BMP in 1 week On discharge Na is 130  Repeat BMP in 3 days   Paroxysmal atrial bibrillation Continue home metoprolol, stop propafenone for now Has hx of ischemic heart disease, afib and HR have been well controlled with the metoprolol.  Echo ordered. In NSR today with HR down in 50-60. Anticoagulation home Xarelto CHA2DS2-VASc Score 4. Follows with Dr., EP. Consider cardio consult for propafenone management - with CAD, stop rythmal and continue AC with Xarelto   Coronary artery disease S/P PCI. No anginal symptoms at this time ECHO- EF 55-65% with mild aortic stenosis and no pulmonary hypertension  Continue aspirin, beta-blocker, high intensity statin   Essential hypertension Continue metoprolol succinate 50 mg Amlodipine added BP controlled   Dyslipidemia Controlled on home Lipitor   Moderate obstructive sleep apnea Sleep study March 2018 apnea-hypopnea index > 20 Compliant with home CPAP   Alcohol use disorder Reports drinks 1 beer daily total of 7 beers a week No history of alcohol withdrawal symptoms Monitor for signs of withdrawal   Code status Full code but does not want prolonged intubation or life support.   Urinary retention Reports being on testosterone in past which was stopped multiple years ago Admits to hx of gynecomastia and follows with urologist.  Encouraged up to bathroom. Check PVR. If  > 500 consider straight cath. Per patient and family has been urinating well with less retention issues