COVID Vaccine Breakthrough Case  Moderna Dose 1 2/11/21 Moderna Dose 2 3/11/21 COVID Positive 9/8/21  Chief Complaint  pt c/o dyspena x 6 months & recenlty can't sleep causing pt to come in today.  History of Present Illness    Patient is an 80-year-old male with past medical history of third-degree heart block status post pacemaker placement, coronary artery disease, mitral regurg, insomnia, hypertension, hyperlipidemia, bioprosthetic aortic valve, GERD, and BPH.  He presented on 09/08/2021 with chief complaint of shortness of breath.  He states that his shortness of breath has been present for 6 months.  He denies any acute worsening of his symptoms that brought him to the emergency department.  He states that he came today because he was tired of listening to his wife complained about his coughing.  He denies being tested for COVID in the past.  He states that he received 2 doses of vaccination in January and February of this year.  He does admit that he has had chills and sweats from time to time, but denies ever taking his temperature.  He has also been coughing up blood.  He denies chest pain or pain/swelling in his lower extremities.  No abdominal symptoms or symptoms otherwise.  He quit smoking 50 years ago.  No illicit drug use otherwise.  He does drink alcohol occasionally.  He denies any contributory family history. The patient denies any recent travel or environmental exposures.  He denies history of underlying lung disease.   In the emergency department, patient was febrile with a temperature of 101.5° F. He was also tachypneic breathing with a rate in the 40s.  He was 72% on room air.  Patient was promptly administered BiPAP, but he ripped this off and was doing okay on high-flow O2 at 15 L thereafter.  Chest x-ray was notable for bilateral infiltrates.  CT chest was negative for pulmonary embolism.  Lactic acid was 4.4.  ABG was unremarkable.  WBC was 14. Patient was administered DuoNebs, Solu-Medrol, Zosyn, and 500 cc of normal saline in the ED.  He was admitted for further management of his COVID-19 pneumonia.  Review of Systems    Twelve point review of systems discussed, pertinent positives and negatives as per above.  Physical Exam Vitals & Measurements T: Warm(Skin)  TMIN: 99.4  °F   TMAX: 101.5  °F   HR: 82(Peripheral)  RR: 26  BP: 118/58  SpO2: 92%  HT: 170.2 cm WT: 64 kg     Gen: Nontoxic, not in acute distress.  HEENT: Normocephalic, Conjunctiva clear, no nasal discharge observed.  CV: S1 S2.  No peripheral edema.  Heme: No active bleeding. No cyanosis or pallor.  Lymphatics: No gross lymphadenopathy.  Lungs:  Coarse lung sounds heard bilaterally.  This is observed bedside.  Mild dyspnea with conversation noted.  GI: Nontender. Soft. Nondistended. Normoactive bowel sounds.  No guarding, rebound, or masses.  Neuro:  No gross neurologic deficits or cranial nerve lesions.  Skin: Intact without lesions or eruptions on exposed surfaces.  Psychiatric:  Pleasant and cooperative.  Assessment/Plan     Acute hypoxic respiratory failure secondary to COVID-19 pneumonia  Coronary artery disease  Third-degree heart block status post pacemaker placement  Bioprosthetic aortic valve  Hypertension  Hyperlipidemia  GERD  BPH   -2 doses of vaccination received in January and February of this year  -onset of COVID-19 symptoms was 6 months ago  -COVID-19 positive on 09/08/2021  -patient currently requiring O2 at 15 L via nasal cannula to maintain saturations greater than 90%.  Patient was on BiPAP in the ER but was refusing this therapy any further. He does not want to be intubated.  He does not want to use BiPAP if needed, even if it was needed to save his life. We discussed the possibility of changing settings to AVAPS if BiPAP was uncomfortable, but the patient stated he did not want to use any machines.  -case discussed with pulmonology.  They have not been formally consulted.  They did not feel that they had anything to add at this point unless patient had elevated inflammatory markers and was requiring actemra or if he changed his mind about how aggressive he wanted to be with his cares.  -trending inflammatory markers  -remdesivir, Decadron, Mucinex, vitamin-C, vitamin-D, zinc ordered.  -supplemental oxygen, RT to evaluate and treat, Acapella, continuous pulse ox  -continue home aspirin, atorvastatin, lisinopril, metoprolol, pantoprazole  -telemetry  -general diet  -gentle hydration with LR at 75 cc/hr  -physical therapy and occupational therapy  -VTE prophylaxis:  Lovenox 40 mg subQ b.i.d.  -code status:  DNR/DNI   I was informed by bedside nurse that passed away at 21:30 PM on 9/15/2021.  CPR was not initiated as patient was on comfort care with a DNR code status. Family members notified.  Time of death was called at 21:30 PM on 9/15/2021.