Age: 71.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute respiratory failure, Adrenal insufficiency, Angiogram pulmonary abnormal, Blood corticotrophin normal, Blood osmolarity decreased
Clinical narrative: Hospitalized;  COVID-19 positive (after fully vaccinated)   Admission Date: 8/27/2021 Discharge Date: 8/31/2021    Active Hospital Problems   Diagnosis Date Noted POA ? Acute idiopathic gout of shoulder 08/31/2021 Yes ? Adrenal insufficiency (HCC) 08/30/2021 Yes ? Hereditary hemochromatosis (HCC) 08/29/2021 Yes ? Hyponatremia 08/27/2021 Yes ? Cardiomyopathy, nonischemic (HCC) 08/28/2014 Yes DETAILS OF HOSPITAL STAY:   PRESENTING PROBLEM: Patient is a 72 y.o. male with a past medical history of suspected pulmonary fibrosis, nonischemic cardiomyopathy, ventricular fibrillation, ICD placement, mural thrombus on chronic warfarin, hypertension, seasonal allergies, chronic obstructive pulmonary disease/asthma who presents with hyponatremia.  In June of this year he was admitted with acute hypoxic respiratory failure and hyponatremia, he was seen by Pulmonology during that admission and he was found to have likely pulmonary fibrosis so was started on triple inhaler p.r.n. and discharged with a prednisone taper and follow-up with Metro pulmonology.   He also had an echocardiogram during that admission which revealed EF 27%, which as been his baseline. He was doing well until he developed bilateral arm pain following work on April 2 to three weeks ago, he had gone to physical therapy and his PCP however his symptoms worsened after continue to workup the boat.  Last night, he had nausea, vomiting, and diarrhea that was followed by chest pain so presented to the emergency department.  HOSPITAL COURSE: Hypoosmolar hyponatremia due to diarrhea, adrenal insufficiency  Na 116 -- > 117-- > 120 -- >122-- >122-- >127-- >128-- >127 -- >125 -- >124 -- >127 Due to adrenal insufficiency, CHF Urine sodium 33, urine osmolality 265, serum osmolality 258 TSH normal Seen by nephrology, continue current treatment Recheck next week by PCP, no need to follow with nephro unless hyponatremia worsening    Adrenal insufficiency Cortisol level 0.9 on admission Cosyntropin stimulation test: 2.5-- > 11.7-- > 14.5  Endocrinology consult: suspect pituitary dysfunction related to hemochromatosis, steroid use or other pituitary etiology  ACTH 19, inappropriately normal, will need MRI of pituitary gland, this could be done outpatiently, and will need follow up with Dr. He was given stress dose steroid with hydrocortisone 25 mg IV every 6 hours, and switched to hydrocortisone 15 mg AM and 5 mg PM. Discussed sick day rules. Double hydrocortisone dose for 2-3 days during acute illness. Recommend to obtain medical alert for adrenal insufficiency.  TSH, FT4 normal. DHEA sulfate 17.6,  In the emergency department, he was noted to have stable vitals.  BMP revealed sodium 116, normal renal function, BNP 3980, negative troponins, no leukocytosis, hemoglobin 10.1 which has been his baseline for several months.  EKG revealed paced rhythm, no significant ST changes, PVC.  Chest x-ray revealed small right pleural effusion and mild bilateral airspace disease.  Incidentally found to be COVID positive in the emergency department.  He was given an aspirin and 500 mL normal saline bolus.  He was admitted to Internal Medicine for further evaluation and management. Initial COVID-19 infection 10/21 Positive COVID-19 PCR on admission CTA 8/28: No central, lobar or proximal segmental pulmonary embolus. Distal segmental and subsegmental vessels are not well evaluated due to respiratory motion. Worsening mediastinal adenopathy. Grossly stable mild peripheral fibrosis throughout both lungs. Mediastinal adenopathy most likely due to COVID-19, will need recheck CT in 2 months  Developed symptoms of diarrhea, nausea and vomiting on 8/26, date of positive test 8/27 On room air since admission, so I do not think this is true reinfection of COVID-19 Nausea, vomiting, diarrhea -resolved  Probable due to COVID-19, adrenal insufficiency