Age: 88.0
Sex: F
Vaccine: COVID19
Symptoms: Urine analysis abnormal, Urine ketone body present, Vaccine breakthrough infection
Clinical narrative: COVID Breakthrough  Pfizer Dose 1 1/21/21 (lot not listed in IRIS/ICARE) Pfizer Dose 2 2/10/21 (lot not listed in IRIS/ICARE) COVID Positive 8/23/21  8/23/21: The patient is an 89-year-old female presents to the emergency department today via EMS from Nursing Home with altered mental status, increasing drowsiness and lethargy.  The patient has a past medical history significant for chronic UTI on prophylactic trimethoprim, neuropathy, hyperlipidemia, obesity, anxiety, mitral valve prolapse, and is bed-bound requiring hoyer lift for transfers.   On arrival to the ED, the patient's temperature is 98.5° F, heart rate 104, respiratory rate 18, saturating 93% on room air with blood pressure 155/101.  Later patient satting 88% on room air requiring 2 L supplemental O2 to maintain sats greater than 90%.  Patient's laboratory studies were significant for glucose 150, ALT 35, AST 44, troponin negative, mg 1.7, urinalysis with 15 ketonuria, moderate hematuria, rare bacteria, 1-3 pyuria, 1-3 RBCs. CT chest shows no acute intrathoracic process, mildly torturous aorta, prior granulomatous disease with scattered calcified granulomas in the lungs and calcified mediastinal and hilar lymph nodes.  CT head shows no acute intracranial findings with age-related volume loss and bilateral white matter disease likely consistent with chronic microangiopathic changes.  Chest x-ray shows abnormal cardiomediastinal silhouette likely secondary to tortuous ectatic thoracic aorta and mild pulmonary venous congestion.  EKG shows sinus tachycardia with PACs, right bundle-branch block and inferior T-waves in inferior leads, heart rate 106, QTC 486. Patient administered NS IV 500 mL in Zofran 4 mg IV in the emergency department.   The patient was seen in the emergency department laying in bed with her son at the bedside.  The patient was very lethargic and unable to arouse/keep awake, but would grimace or grown to painful stimuli.  The patient is currently on 2 L supplemental O2 via nasal cannula and saturating in the 90s.  The patient's son reports that she is bed-bound at baseline and they have to use a lift to get her up.  She is a DNR/DNI status.  8/25/21: Patient is admitted hospital, neuro checks performed per protocol, her mental status has improved, has some baseline cognitive deficits and has remained stable. Stroke workup done with the carotid Doppler and echocardiogram is unremarkable.  She does not have any new neurological deficits.  Patient has been febrile in the hospital, her COVID-19 test is positive.  Inflammatory markers ordered, pretty unremarkable.  Chest x-ray negative for infiltrate.  Admission patient was placed on oxygen as she was noted to have 1 episode of hypoxia with pulse ox 88%.  Oxygen has been weaned off and the patient has remained on room air, no further hypoxia noted.  Patient does not need any treatment for COVID-19 at this time as there is no hypoxia on inflammatory markers are at baseline.  She is discharged back to the long-term care facility in stable condition.  Continue Tylenol and the adequate oral hydration.  Monitor pulse ox and the transfer the patient back to ED if hypoxia noted.