Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Blood ketone body absent, Blood lactic acid, Blood magnesium increased, Blood osmolarity increased, Blood pH decreased
Clinical narrative: COVID Vaccine Breakthrough Case  Pfizer Dose 1 3/8/21 (EN6199) Pfizer Dose 2 3/31/12 (EN6207) COVID Negative 10/25/21 COVID Positive 11/5/21  10/25/21: Patient is a 66-year-old male the past medical history of type 2 diabetes, COPD, CAD with stents, hypertension, and seizure disorder who presented to the ER via EMS due to unresponsiveness.  Patient lives at home with roommates, per EMS report he has been intermittently unresponsive the past 4 days and lying on the floor.  He has been smoking less than usual.  Further history is limited due to patient's current condition, he is not currently responding to questioning.   His sister was contacted.  Reports patient's roommate called her today stating patient has been on the ground and unresponsive for possibly 4 days. It is the patient's sister who called for an ambulance.  She states seizures have been well controlled.  As far she knows he has been compliant with his diabetic medications.   Substance use:  unclear, does smoke cigarettes  Family history:  Diabetes in both parents.   In the ED, patient was minimally responsive with GCS 9-10. He was hypothermic with a temperature of 95.6°.  He was also noted to be tachycardic with heart rate in the 110s, blood pressure initially 79/60, he was placed on 2 L of oxygen.  Lab work significant for sodium 146, CO2 12, anion gap 40, glucose 1238, creatinine 4.38, serum osm 396, alk-phos 169, magnesium 4.7, lactic acid 5.0, lipase 426. WBC 24, hemoglobin 17.2.  ABG pH 7.1, pCO2 46, PO2 92, bicarb 14. Troponin was negative, acetone negative. Chest x-ray showed no acute process, head CT showed changes representing chronic microvascular ischemic changes, no acute changes.  EKG showed AFib with RVR, rate 114. He received 1 L normal saline via EMS, 2.5 L LR in the ER.  He was given Zosyn and started on an insulin drip.  11/17/21: Patient is a 66-year-old male the past medical history of type 2 diabetes, COPD, CAD with stents, hypertension, and seizure disorder who presented to the ER on 10/25 via EMS due to unresponsiveness.  It is believed that patient may have been unresponsive for as long as 4 days. In the ED, patient was minimally responsive with GCS 9-10.  He was hypothermic with a temperature of 95.6°.  He was also noted to be tachycardic with heart rate in the 110s, blood pressure initially 79/60, he was placed on 2 L of oxygen.  Lab work significant for sodium 146, CO2 12, anion gap 40, glucose 1238, creatinine 4.38, serum osm 396, alk-phos 169, magnesium 4.7, lactic acid 5.0, lipase 426. WBC 24, hemoglobin 17.2.  ABG pH 7.1, pCO2 46, PO2 92, bicarb 14. Troponin was negative, acetone negative.  Chest x-ray showed no acute process, head CT showed changes representing chronic microvascular ischemic changes, no acute changes.  EKG showed AFib with RVR, rate 114. He received 1 L normal saline via EMS, 2.5 L LR in the ER.  He was given Zosyn and started on an insulin drip. On 10/26, the day following admission a code blue was called on the patient.  CPR and chest compressions were started, he received 2 amps of bicarb for acidosis as well as 1 round of epi, ROSC was achieved.  Patient was subsequently intubated.  Patient was extubated on 11/2 and moved to the floor on 11/3.  During the time that he was intubated nephrology and pulmonology were consulted and manged his AKI and vent settings.  While on the floor patient worked with PT/OT and was undergoing swallow evaluations while looking for placement.  Patient was placed on a dysphagia diet. On 11/5 patient tested positive for COVID19 after his sister who had visited him tested positive.  Patient was thus unable to transfer until he was out of the quarantine window. Patient remained asymptomatic during this time.  He was then able to be transferred.