COVID Breakthrough  Moderna Dose 1 2/16/21 (023M20A) Moderna Dose 2 3/16/21 (031A21A) Presented to ED but cough was attributed to COPD and pt was not tested 8/14/21 COVID Positive 8/17/21 Went to family medicine clinic and diagnosed with COVID 8/17/21  8/18/21: The patient is a 70-year-old male who presents to the emergency department today with worsening shortness of breath and COVID-19 symptoms, tested positive on 08/17. The patient has a past medical history significant for COPD, asthma, history of smoking, diabetes mellitus type 2, hypertension, hyperlipidemia, GERD, fatty liver, and obesity.  Of note, patient was seen in ED on 08/14 and diagnosed with acute COPD exacerbation and hyponatremia, prescribed azithromycin and prednisone.  Patient spoke with his PCP via telehealth on 08/17 and had COVID-19 test ordered along with chest x-ray.  Patient reports he was seen in Iowa city for an MRI/MRA of his left carotid artery, which was found to be 80% blocked, any happen to look at his chart and noticed that he had a temperature of 100.4° F. The patient is fully vaccinated for COVID-19.   On arrival to the ED, the patient's temperature was 100.1° F, heart rate 112, respiratory rate 18, saturating 93% on room air, then decreasing to 88% on 1 L requiring 2 L supplemental O2 via nasal cannula with blood pressure 109/73 and 7/10 severity left lower chest/rib pain.  The patient's laboratory studies were significant for anion gap 18, glucose 148, BUN 34, CR 1.53, ALT 52, AST 56, lactate 2.3, troponin negative, CRP 14.3, ESR 48, WBC 12.45, VBG: PH 7.38, pCO2 50, PO2 31, HC03 29, base excess +4, O2 saturation 57%.  Blood cultures obtained x2.  Chest x-ray is abnormal and shows increasing bibasilar pneumonia.  EKG shows sinus rhythm, heart rate 114, QTC 449 with left atrial enlargement.  The patient was administered DuoNeb 3 mL, aspirin 324 mg p.o., magnesium sulfate 2 g IV, NS IV x1 L, ceftriaxone 1 g IV, and acetaminophen 1 g p.o. in the emergency department.   The patient was seen on the medical pulmonary unit sitting on the side of his bed on 2 L supplemental O2 via nasal cannula.  He reports that last week in Iowa city he noticed he had that temperature of a 100.4° F, but did not start feeling sick until last Thursday.  He reports he has been feeling worsening shortness of breath, chills, fevers up and down, headaches, some phlegm associated with cough, left chest/rib pain, and a decreased appetite.  He reports he has been taking his azithromycin and prednisone as prescribed on 08/14.  He denies any current smoking.  He reports he is fully vaccinated for COVID-19.  He was just recently diagnosed with carotid artery stenosis of the left carotid, which is apparently 80% blocked.  9/3/21: The patient is a 70-year-old male who presents to the emergency department today with worsening shortness of breath and COVID-19 symptoms, tested positive on 08/17. The patient has a past medical history significant for COPD, asthma, history of smoking, diabetes mellitus type 2, hypertension, hyperlipidemia, GERD, fatty liver, and obesity.  Of note, patient was seen in ED on 08/14 and diagnosed with acute COPD exacerbation and hyponatremia, prescribed azithromycin and prednisone.  Patient spoke with his PCP via telehealth on 08/17 and had COVID-19 test ordered along with chest x-ray.  Patient reports he was seen in Iowa city for an MRI/MRA of his left carotid artery, which was found to be 80% blocked, any happen to look at his chart and noticed that he had a temperature of 100.4° F. The patient is fully vaccinated for COVID-19. Patient was then admitted with acute hypoxic respiratory COVID-19 pneumonia, AKI, anion gap metabolic acidosis, sepsis,  type 2 diabetes mellitus.  Patient had a prolonged stay in the hospital required to be transferred to the ICU and was intubated put on mechanical ventilation and extubated after 4 days.  Patient general condition improved and discharged home