Age: 83.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood folate
Clinical narrative: Reason for admission: This 83-year-old gentleman was transferred to our care from a Hospital because of right lung pneumonia, positive coronavirus assay, and ulceration noted in the distal portion of the patient's aortic arch.   History of present illness: Patient is 83 years old, and he lives with his wife and two of their daughters.  He has a history of paroxysmal atrial fibrillation.  He is chronically on Amiodarone therapy and Apixaban.  The patient also has peripheral vascular disease; the patient had bilateral carotid endarterectomies performed in 2018.  The patient also has a history of chronic obstructive pulmonary disease.  From reading the last note from his pulmonologist the patient's FEV1 was 37% of predicted.     The patient also has a history of congestive heart failure. The patient's left ventricular ejection fraction was "at the lower limits of normal" on his last echocardiogram from May, 2020.  However, the actual ejection fraction could not be measured because the patient was in atrial fibrillation with a rapid ventricular response.  The patient had a nuclear medicine perfusion scan done July, 2020, and this showed that the patient's left ventricular ejection fraction was 46%.  No perfusion or reperfusion abnormalities were noted.   The patient states that on a normal day that he gets short of breath walking to and from the mailbox. The patient states that it is about 100 yards from his house to the mailbox.  The patient can walk to the mailbox at a slow pace.  He stops and rests when he gets to the end of the driveway.  The patient states that he will usually have to stop and rest about halfway between the mailbox and his house when he is walking back to the house. The patient sleeps on one pillow.  He does not have paroxysmal nocturnal dyspnea.  The patient states that he has had edema in his feet, ankles, and lower legs for about one year.   The patient has not had any chest pain, be it retrosternal or pleuritic, whenever he exerts himself.  He is only having dyspnea.   The patient states that he mostly went into the emergency department at the Hospital yesterday evening because of worsening shortness of breath.  The patient states that he had a cough about a week ago.  This cough lasted for about three days, and it was productive of small amounts of white sputum.  It was not productive of purulent sputum.  The patient states that after the cough resolved on Wednesday or Thursday of last week he has noticed that he is more short of breath with less exertion.  The patient's daughter checked the patient's temperature yesterday afternoon, and it was 101 °F.  This constellation of symptoms is what led the patient go to an urgent care facility. The patient was subsequently transferred directly to the emergency department at the Hospital.   The patient was tested for coronavirus, and his PCR assay is positive.  The patient states that he and his wife both got coronavirus vaccinations in July.  The patient was given 6 mg of IV Dexamethasone at the Hospital.  The patient also had a CT angiogram of the chest performed.  The patient did not have any evidence for pulmonary emboli.  However, the patient does have evidence for small right pleural effusion and lung infiltrate primarily in the right lower lobe.  There does appear to be some honeycombing in the lateral portion of the right lower lobe.  Also noted was an area of ulceration in the distal portion of the patient's aortic arch associated with aortic wall thickening.  There is also a possible intramural hematoma present.  The patient was going to be admitted to the Hospital, but they did not have a bed available.  The patient was subsequently transferred here to treat his pneumonia, his coronavirus infection, and for cardiac surgery consultation because of his aortic arch ulcer.   The patient is not having any retrosternal chest pain or pleuritic chest pain.  The patient quit smoking cigarettes 6-7 years ago.  The patient states that he normally does not have a cough.  The cough that he had last week was out of character for him.  The patient has been anticoagulated for a number of years because of his history of atrial fibrillation.  He is also chronically on Amiodarone therapy   Urinalysis is normal except for 1+ albumin being present.  Pro-beta-natruretic peptide is 2128.  CMP reveals the following: sodium 140, potassium 4.1, chloride 101, bicarbonate 28, BUN 25, creatinine 1.36 (creatinine was 1.55 four months ago), glucose 113, albumin 3.4, calcium 7.8, AST 35, ALT 20, alkaline phosphatase 61, total bilirubin 1.0, total protein 6.0, and ionoized calcium 4.3.  CBC reveals a white count of 4.14, hemoglobin 11.3, hematocrit 35.2%, MCV 109.7, and platelet count is 162,000.  Hemoglobin level was 13.0 three months ago.  Coronavirus assay via PCR is positive.   Problems: 1.  Right lower lobe pneumonia 2.  Positive coronavirus assay 3.  Severe chronic obstructive pulmonary disease 4.  Aortic arch ulcer 5.  Suspected congestive heart failure 6.  Peripheral vascular disease 7.  Proximal atrial fibrillation 8.  Hypothyroidism 9.  Glaucoma 10.  Chronic renal failure; the patient's creatinine is currently 1.36 11.  Anemia   Discussion: The patient has been admitted because of his myriad of problems.  We will treat his right lower lobe pneumonia with IV Azithromycin and IV Ceftriaxone for community-acquired pneumonia.  The patient does not have any infiltrate in his left lung.  Most of the infiltrate is present in the patient's right lung on chest x-ray.  I suspect this is probably from a community-acquired pneumonia.  I do not think the patient has significant coronavirus pneumonia since most of the infiltrate is located in one lobe of the lung.  We will send a sputum specimen for Gram stain and culture.  We shall send a urine specimen to strive for Streptococcus pneumoniae antigen.  Because of the patient's hypoxemia and his positive coronavirus assay, the patient needs to be treated with IV Remdesivir and IV Dexamethasone.   We will treat the patient's COPD with the following medications: Tiotropium two puffs daily, Advair 230-21 two puffs twice daily, and Albuterol 2 puffs every 4 hours as needed.   With regard to the patient's aortic arch ulcer, we will consult cardiothoracic surgery for their opinion about what, if anything, needs to be done about this.   Regarding the patient's probable congestive heart failure, we will get an echocardiogram on this gentleman to determine what his left ventricular ejection fraction is.  The patient is in sinus rhythm on his EKG right now. We will continue the patient on Metoprolol XL 75 mg daily to treat his congestive heart failure.  We will start the patient on Losartan 25 mg daily because he is hypertensive and because he apparently has a depressed ejection fraction based on the results of his last nuclear medicine stress test in July, 2020.  I will stop the patient's diuretic therapy for the time being while we sort things out.   With regard to the patient's paroxysmal atrial fibrillation, we will continue the patient on Amiodarone 100 mg daily.  We will continue to anticoagulate with Apixaban 5 mg twice daily.   We shall continue the patient on his usual dose of Levothyroxine to treat his hypothyroidism.  We shall continue the patient on his usual Brimonidine eye drops to treat his glaucoma.  The patient's chronic renal failure is stable; hjis creatinine is currently 1.36.   With regard to the patient's anemia, his hemoglobin is 11.3.  Three months ago, the patient's hemoglobin level was 13.0.  The patient's MCV is elevated.  The patient just had blood work done earlier this month.  The patient's percent transferrin saturation at that time was 45%.  Serum iron level was 111, and total iron binding capacity was 244.  Ferritin level was 310.  Vitamin B12 level was 684, which is within normal limits.  Serum folic acid level was 15.0, which is also within normal limits.  I am not certain what might be causing the patient's mild anemia.  Obviously, the patient is not iron deficient.  He also does not have B12 or folic acid deficiency.  It is hard to say what might be causing the anemia  at this point in time.  PATIENT REMAINS HOSPITALIZED AT THE TIME OF THIS REPORT