Age: 51.0
Sex: M
Vaccine: COVID19
Symptoms: Serum ferritin increased, Sinus congestion, Streptococcus test, Troponin normal, Vaccine breakthrough infection
Clinical narrative: patient vaccinated for COVID (4/15 and 3/12), admitted 8/14, tested positive for COVID 8/14/2021. discharged 8/28 to home  Pt was diagnosed with COVID-19 on 07/22. This is just to report that the pt got the vaccine.  Date of COVID-19 test 07/22 Date of admission: 08/14 Admitted for cough and SOA due to COVID and bacterial PNA- started on abx and dexamethasone  History Of Present Illness Patient is a 51 y.o. male with a PMH of HTN and small lymphocytic lymphoma. He was diagnosed with Covid on July 22. (Previously vaccinated with moderna 3/13, 4/15) His symptoms started two days prior on July 20 with with nasal and sinus congestion. He states he finished quarantine on 8/1 and seemed to be symptom free, then on 8/8 he started to feel fatigued and developed fever/chills, SOA with talking or exertion and a dry cough. He had a telehealth appointment with his oncologist on 8/10 due to not feeling well enough to make his appointment in person and was advised to be monitor his symptoms and present for further care if he did not improve. Since the fevers did not improve he presented to the local ED on 8/11. There they did a CXR and diagnosed him with pneumonia. They started him on cefdinir and azithromycin PO. He also contact his ID physician who advised him to have a CT chest done for further evaluation. He states the CT was completed on 8/12 and the provider who completed the exam started him on oral steroids due to findings of bilateral pneumonia. He had two days of steroids and did not have any doses this morning. He did take his abx this morning. Currently he continues to endorses the above symptoms and reports that he has had fevers on a daily basis since the 8th, up to 102.9. He states the fever breaks with tylenol but then comes back. His cough is non-productive. He denies rashes, HA, URI symptoms, wheezing, pleuritic pain or chest pain, abdominal pain, N/V or constipation. He does report some diarrhea with the abx. He states he has not had his chemo medications since he started feeling so sick.    Patient is a 51 y.o. male with a PMH of HTN and small lymphocytic lymphoma. He was diagnosed with Covid on July 22 after onset of congestion July 20 and symptoms largely resolved by 8/1 when he completed his quarantine. Then on 8/8 he developed fatigue, fever, chills, SOA and a dry cough. He went to his local ED on 8/11 and was diagnosed with pneumonia and sent out with azithromycin and cefdinir. He had a Chest CT done the following day 8/12 at the recommendation of his ID physician. The CT showed bilateral pneumonia so he was also given steroids. He presents today due to continued fevers up to 102.9 and lack of symptomatic improvement.    On presentation, his RR is elevated at 27 and oxygen saturation is stable at 96%. He is otherwise afebrile and hemodynamically stable. Initial labwork notable for normal WBC, mild normocytic anemia, elevated inflammatory markers (ferritin 1961, LDH 351, CRP 87.6), CMP with mild hyponatremia, hypokalemia (K 3.5), lactate, BNP and troponin WNL. VBG without acidosis or alkalosis. Chest x-ray was obtained showing bilateral infiltrates with possible right upper lobe consolidation. EKG shows sinus rhythm with PVC, no visualized ST elevation/depression.  Blood cultures were obtained and empiric abx started with cefepime and vancomycin.    Covid-19 infection with concern for co-existing bacterial pneumonia  -Covid + 7/22, sx of congestion resolved by 8/1, new onset of cough, fever, chills, SOA, starting 8/8, dx with CAP at outside ED 8/11, started on azithromycin and cefdinir, reportedly had CT done 8/12 showing bilateral pneumonia and started on steroids  -afebrile, RR elevated, oxygen stable on RA. Exam with rales most prominent in the left upper lobe consistent with infiltrate noted on 8/5 PET. Inflammatory markers elevated as above.  -X-ray 8/14 personally visualized. Report notes ?Bilateral patchy airspace disease, with right upper lobe consolidation. Atypical infectious etiology should be considered. Follow-up to radiographic resolution is recommended.?  -follows with ID outpatient, Dr. who advised admission for infectious work-up and treatment  -Covid and respp pending, not meeting criteria for remdesivir  Plan: -obtain ambulatory saturation and procalcitonin -ID aware of patient, will consult formally in am, appreciate continued recs -obtain records and CT report in am  -follow blood cultures  -fungal serology, Abs and beta glucan ordered -urine legionella, strep and histo pending  -continue empiric abx with vancomycin and cefepime -continue azithromycin, final dose of z-pack tomorrow morning  -continue dex 6m daily PO  -initiate supplemental oxygen as needed to maintain saturation >92% -symptoamtic management with benzonatate pearls for dry cough   Small lymphocytic lymphoma  -follow with oncology, on chemotherapy with obinutuzumab, per chart review last seen 8/10  -PET/CT 8/5 showed slight decrease lesions suggestive of response to treatment. Interval development of multiple hypermetabolic left lower lobe pulmonary opacities also noted and likely representing inflammatory or infectious process in the acute setting.  -chemo infusion planned for 8/11 cancelled due to acute illness, will consider resuming once illness resolves Plan: -oncology aware of admission, will consult formally in am  -continue to hold chemotherapy in setting of acute infection   Hypokalemia  -potassium 3.5 -replace 40meq PO -continue to monitor and replace as needed   Morbid obesity - BMI 41.05, complicates all aspects of care   Review of Systems  Constitutional: Positive for chills and fever. Negative for unexpected weight change.  HENT: Negative for congestion, rhinorrhea, sinus pressure, sinus pain, sore throat and trouble swallowing.   Eyes: Negative for visual disturbance.  Respiratory: Positive for cough and shortness of breath. Negative for wheezing.   Cardiovascular: Negative for chest pain and leg swelling.  Gastrointestinal: Positive for diarrhea (following abx). Negative for abdominal pain, blood in stool, constipation, nausea and vomiting.  Genitourinary: Negative for difficulty urinating and dysuria.  Musculoskeletal: Negative for joint swelling.  Skin: Negative for rash and wound.  Neurological: Negative for dizziness, weakness, light-headedness, numbness and headaches.  Hematological: Does not bruise/bleed easily.  Psychiatric/Behavioral: Negative for confusion.     Hospitalization Admit Date/Time: 8/14/2021  1:24 PM Discharge Date: 8/28/2021  Referring provider name and address:  No referring provider defined for this encounter.   Chief Concern, Brief History of Present Illness, and Hospital Course   Patient is a 51 y.o. male who was admitted on 8/14 with a breakthrough COVID-19 infection despite Moderna vaccination. He required high flow nasal cannula and ICU care. He completed a course of dexamethasone (including escalation to ARDS dosing) and remdesivir. He also received treatment for hospital-acquired pneumonia. He has now improved, and has been weaned to room air.   Acute hypoxic respiratory failure, due to severe COVID-19 pneumonia in an immunocompromised host S/p Moderna vaccination in 3-4/2021 S/p dexamethasone and remdesivir here Completed ARDS dosing of dexamethasone on 8/28 Now on room air   Hospital acquired pneumonia Infectious workup was negative S/p vancomycin and cefepime