Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Lung infiltration, Malaise, Pain, Prohormone brain natriuretic peptide increased, Pulmonary congestion
Clinical narrative: COVID Vaccine Breakthrough Case  J&J Dose 5/4/21 (201A21A COVID Positive 11/21/21  11/21/21: Patient is a 59 year old male presented to ED via EMS from a facility with reports of shortness of breath.  The patient has felt unwell for the past 3 days.  He has had body aches, productive, wheezes, shortness of breath and decreased appetite and oral intake.  He was recently started on a course Azithromycin and albuterol but has not had no improvements in his symptoms.  He developed increased shortness of breath today and is reported to ED for further evaluation.  He denies any abdominal pain, nausea vomiting or diarrhea.  He does endorse some chest tightness especially with inspiration.  He was COVID vaccinated with Johnson and Johnson approximately 6 months ago.  He has a past medical history significant for hypertension, morbid obesity, type 2 diabetes mellitus, asthma and coronary artery disease status post stenting & CABG.  On arrival to ED patient was febrile 101.2 saturating at 95% on 2 L NC.  Laboratory findings were significant for hyponatremia 132. Hypomagnesemia 1.2.  Lactic acidosis 4.9. ProBNP 491. Anemia 11.4.  Hyperglycemia 196. Rapid COVID positive. Chest x-ray showed cardiomegaly and pulmonary vascular congestion.  Patchy bibasilar airspace disease could represent atelectasis versus infiltrates. Levaquin was initiated in ED.  Patient received DuoNeb treatment and Solu-Medrol, as well as acetaminophen in ER.  IV hydration was given with NS 0.9% 2 L bolus.  11/30/21:  Patient is a 59 year old male presented to EDwith reports of shortness of breath.  The patient has felt unwell for the past 3 days.  He has had body aches, productive, wheezes, shortness of breath and decreased appetite and oral intake.  He was recently started on a course Azithromycin and albuterol but has not had no improvements in his symptoms.  He developed increased shortness of breath today and is reported to ED for further evaluation.  He denies any abdominal pain, nausea vomiting or diarrhea.  He does endorse some chest tightness especially with inspiration.  He was COVID vaccinated with Johnson and Johnson approximately 6 months ago.  He has a past medical history significant for hypertension, morbid obesity, type 2 diabetes mellitus, asthma and coronary artery disease status post stenting & CABG.  On arrival to ED patient was febrile 101.2 saturating at 95% on 2 L NC.  Laboratory findings were significant for hyponatremia 132. Hypomagnesemia 1.2.  Lactic acidosis 4.9. ProBNP 491. Anemia 11.4.  Hyperglycemia 196. Rapid COVID positive. Chest x-ray showed cardiomegaly and pulmonary vascular congestion.  Patchy bibasilar airspace disease could represent atelectasis versus infiltrates. Levaquin was initiated in ED.  Patient received DuoNeb treatment and Solu-Medrol, as well as acetaminophen in ER.  IV hydration was given with NS 0.9% 2 L bolus.  The patient was treated for acute hypoxemic respiratory failure due to COVID-19 infection and symptoms have improved  Patient will be discharged to original facility and he will continue his home medications.  We recommend him to see his primary care provider in 3-5 days