Age: 92.0
Sex: M
Vaccine: COVID19
Symptoms: Chronic kidney disease, Condition aggravated, Confusional state, Constipation, Contusion
Clinical narrative: COVID Vaccine Breakthrough Case  Moderna Dose 1 4/1/21 (lot not listed in database) Moderna Dose 2 4/29/21 (lot not listed in database) COVID Positive 8/27/21  8/27/21: Patient is a 93 year old male who presented to ED with his daughter with complaints of shortness of breath. Patient lives at home with his disabled son, his daughter checks on him daily. She visited him today and found him in bed vomiting. She checked his pulse ox and stated she was unable to get him above 80%. He does not wear supplemental oxygen at baseline. He has a past medical history significant for coronary artery disease status post stenting, severe aortic stenosis, congestive heart failure, hypertension, paroxysmal atrial fibrillation not on anticoagulation, hyperlipidemia, abdominal aortic aneurysm, history of MI history, history of prostate cancer, anemia, chronic hematuria, cognitive impairment, former tobacco user and chronic pain. On Tuesday of this week the patient did sustain a fall while home alone, daughter is unsure how the fall occurred or if the patient hit his head. He was seen by his PCP, on Wednesday. Outpatient CT head was ordered but has not been done yet. He does have bruising to his left elbow. There was also some suspicion for aspiration pneumonia and patient started on Levaquin x7 days.  On arrival to ER patient was febrile 101.6 and hypoxic on room air at 82%.  3 L nasal cannula was applied with improvement oxygenation saturations to 96%.  Laboratory findings were significant for CKD G3a creatinine 1.39. ProBNP 2899. Troponin 0.05.  Pancytopenia WBC 3.85 and RBC 3.63.  Thrombocytopenia platelets 109. Urinalysis showed large hematuria.  Chest x-ray was unremarkable.  Vancomycin and Zosyn were initiated in ED.  IV fluid hydration was given with NS 0.9% 500 mL bolus.  Patient was seen and examined in ED with his daughter at bedside. Patient states he feels better with oxygen on and is less nauseated. Denies chest pain. Has not been eating and drinking normally. Has had generalized weakness. Daughter feels his confusion has progressively worsened, was going to f/u with neurology on outpatient basis. He does have CHF but is only taking his lasix prn. Endorses constipation. On opioids for chronic pain related to an accident several years ago. No recent fevers. Pt has been fully Covid-19 vaccinated.  9/7/21: Patient is a 93-year-old male presented on 08/27/2020 chief complaint of shortness of breath.  His symptoms were initially thought to be secondary to aspiration pneumonia.  However, he tested positive for COVID-19.  He was treated for both with steroids, antibiotics, and vitamins.  Patient spent several days in the hospital pending placement as it was difficult to find a skilled nursing facility that would take him with his COVID-19 positive status.  On 09/07/2021, he was deemed COVID recovered and was discharged to a residential facility.  Of note, the patient was requiring O2 at 2 liters/minute via nasal cannula to adequate saturations at time of discharge.  He also had elevated blood pressures in the hospital and will need follow-up for hypertension management.