Discharge Provider:  MD Primary Care Provider:  MD Admission Date: 1/6/2023 Discharge Date: 1/15/23 COVID positive date: 01/06/2023  PRESENTING PROBLEM: Community acquired bacterial pneumonia [J15.9] Pneumonia of both lungs due to infectious organism, unspecified part of lung [J18.9] COVID-19 [U07.1]   HOSPITAL COURSE:   50-year-old male with PMH of  small-cell lung cancer with intracranial metastases ( with history of stereotactic radiation therapy, now on active whole-brain radiation therapy), ILD and  chronic hypoxic respiratory failure on 3 L oxygen at baseline and 6 L with activity,  chronic hyponatremia,  hypertension, OSA, chronic pain,  who presented with shortness of breath and generalized weakness.  Notably, he was recently found to be COVID positive on 01/04.   On admission, CTA thorax negative for PE, but did show:   new bilateral pneumonia, progression of lung cancer,  severe pulmonary fibrosis, evidence of pulmonary hypertension.  He was treated for superimposed bacterial pneumonia  as well as COVID pneumonia.   He received 7 day course of cefepime and 3 day course of azithromycin.   He was maintained on Bactrim for PJP prophylaxis.  For code, he was treated with dexamethasone   For 7 days until discharge, remdesivir for 5 days, and DVT prophylaxis.   His respiratory status improved back to baseline.      Dispo planning complicated by patient's  active radiation therapy.  Patient had been planned for radiation therapy but missed his treatments due to being inpatient.  Discussed case  with Rad Onc from our institution recommended that patient follow-up with his Rad Onc.  Case was discussed with his  Rad Onc treatment team  who shared that patient had been on a specialized individual protocol   Due to both the fact that he has had history of stereotactic radiation therapy in setting of brainstem mass,  but now on home brain radiation therapy, as well as the fact that he  had  missed prior radiation treatments due to recurrent hospitalizations.  Initially was planned for radiation therapy to be completed within 2 weeks but had been prolonged for at least a month now.  Would  benefit from discussion with their team to decide whether or not to resume radiation and had what schedule.  Additionally, would be best served if he continued his radiation therapy with their center  due to his individualized protocol.    Hospital course was complicated by progressively worsening hyponatremia due to SIADH.  Patient was treated with 1.5 L fluid restriction, salt tabs initially 1 g but then increased to 2 g 3 times a day, diuresis with torsemide and Lasix, and eventually nephrology consulted due to worsening  hyponatremia despite these efforts, with nadir of 113.  Nephrology gave dose of tolvaptan and sodium increased from 117 to 134   within 16 hours.  Patient was  then treated with D5W   Infusion.  Note from Nephrology at that time recommended to avoid further doses of tolvaptan given over-correction.  However, the following day, sodium was around 130 to 132. On-call  Nephrology (different provider) at that time gave a dose of tolvaptan for SIADH.  Sodium was monitored overnight and remained stable at  131-134.  Case was discussed with  on-call Nephrology the following day (another different provider) and  patient was not recommended for discharge on tolvaptan.  Patient discharged with 1.5 L fluid restriction, salt tabs 1 g 3 times a day, torsemide 10 mg oral daily  to replace home Lasix.  Patient started to follow closely and establish with  nephrology. Renal Associates office contacted prior to discharge to arrange follow up and have follow up BMP.