Age: 55.0
Sex: M
Vaccine: COVID19
Symptoms: Anaemia, Anticoagulation drug level below therapeutic, Asymptomatic COVID-19, COVID-19, Chest X-ray normal
Clinical narrative: COVID Vaccine Breakthrough Case  Moderna Dose 1 3/25/21 (016B21A) Moderna Dose 2 4/22/21 (048B21A) COVID Positive 11/22/21  11/22/21: Patient is a 56 year old male with a recent past history of post-polypectomy bleeding who presented to ED today with complaints of maroon-colored stool that started yesterday evening. Patient has a history of colonic polyps and underwent a routine colonoscopy with Dr. on 11/10 with removal of polyps, three days later the patient was admitted for an acute GI bleed secondary to post-polypectomy bleeding. Dr. performed a follow up colonoscopy on 11/15 with hemostasis. The patient has a history of mechanical aortic valve replacement in 2020, he is anticoagulated on Coumadin and Lovenox b.i.d..  He denies any lightheadedness or dizziness.  No shortness of breath or chest pain.  He is not experiencing any abdominal pain.  He denies any nausea or vomiting.  Has a past medical history significant for hypertension.  On arrival to ED the patient was tachycardic at 105. Laboratory findings were significant for anemia HGB 10.6. Subtherapeutic INR 1.8.  Chest x-ray unremarkable.  CT abdomen showed additional clip in the cecum with an additional clip in the sigmoid possibly related to recent colonoscopy. No ileus, obstruction inflammation or free air. Patient received Protonix 80 mg IV and fluid resuscitation with NS 0.9% 1 L bolus.  11/26/21: Patient is 56-year-old male with past medical history of metallic aortic valve replacement in 2020 on chronic warfarin therapy and hypertension.  She underwent a colonoscopy with Dr. 1/11/2021, with removal of 4 colonic polyps with the largest in the cecum. His warfarin was held for 5 days and patient was placed on full-dose Lovenox in preparation for colonoscopy prior to that The patient subsequently did well until he was admitted 11/13/2021, with the post-polypectomy bleeding. . He was admitted on 11/13/2021 for post polypectomy GI bleed.  He did not require any transfusion.  He underwent colonoscopy with hemostasis of previous polypectomy and removal of additional 2 polyps with hemostasis.  Patient was discharged home in stable condition without requiring transfusion.  However, he came back again to the ER on 11/22/2021 with complaint of dark blood movements.  His INR was subtherapeutic at 1.8.  Patient was kept NPO and was started with IV Protonix drip.  His home medication warfarin was held and patient was put on Lovenox until 12 hours prior to planned colonoscopy procedure.  Serial CBC was obtained.  His hemoglobin continues to trend down.  He received 4 units of transfusion during his hospital stay. He underwent colonoscopy on 11/24/2021 which revealed bleeding possible active pos polypectomy site. Hemostasis was achieved with epinephrine injection.  Postprocedure, he remained hemodynamically stable with stable hemoglobin. Patient did not have any active rectal bleeding post procedure.  Case was discussed with cardiologist on-call Dr. who recommended to hold Lovenox bridging.  She recommended to continue with his home dose of warfarin with a target of lower end of INR range.  Patient was continued with warfarin 5 mg p.o. daily.  During his hospital stay, INR remained between 1.8-1.9.  Patient will be discharged home with warfarin without Lovenox bridging in view of high risk of bleeding.  Patient will have repeat CBC and INR in 3 days time.  Nasopharyngeal swab obtained as admission screening came back positive.  However, patient remained asymptomatic without any oxygen requirement.  Patient is fully vaccinated for COVID-19.  He is being discharged with COVID-19 safe at home program.  He was instructed to self isolate at home for at least 10 days from day of diagnosis. Patient will follow-up with PMD in 3-5 days.