COVID Vaccine Breakthrough Case  Pfizer Dose 1 3/3/21 Pfizer Dose 2 3/28/21 COVID Positive 9/10/21          Birth Date:(privacy)     History of Present Illness    Patient is a pleasant 81-year-old male with past medical history of BPPV, CAD, CHF, hyperlipidemia, hypertension, obesity, recent history of COVID-19 pneumonia, history of COPD comes in with chief complaint right-sided risk swelling/pain.  Clinical picture started this past 2 to stay patient suddenly started noticing swelling discomfort of his wrist swelling and redness started to increase and progressed approximately a from right wrist was not improving so came into the emergency department for further evaluation. In ED lab work demonstrated no significant leukocytosis, however there is elevation of ESR, CRP. Imaging of right wrist demonstrated degenerative changes with no fracture.  Forearm imaging with sclerosis in the lunate will out ulnar positive variance.  Patient also developed some hypoxia/shortness of breath well in ED placed on 3 L oxygen breathing treatments for possible mild COPD exacerbation.  Chest x-ray was ordered demonstrated pulmonary vascular congestion and patchy airspace disease in bilateral lungs concerning for pulmonary infiltrate.  In emergency room, patient received analgesics, IV fluids, breathing treatment.  At bedside lying comfortably in bed currently denies lightheadedness, dizziness, chills, fevers, nausea, vomiting, diarrhea, chest pain, palpitations, abdominal pain, paresthesia or swelling of extremities, dyspnea.  Pain discomfort in right wrist as well controlled after analgesics. Of note patient reports he was admitted last month  for COVID-19 pneumonia was discharged only last week to home without any supplemental oxygen.  Reports he has been compliant with his home medications as prescribed though did not take his meds this morning.  He denies being on blood thinners.  He does report previous history of left wrist pain/joint infection which required washout hospitalization and antibiotics.  Otherwise denies alcohol, marijuana/recreational drugs, takes over-the-counter vitamins.  Family history otherwise reviewed and noncontributory to presenting finding.  Review of Systems    Constitutional: No fevers, chills, sweats  Eye: No recent visual problems  ENMT: No ear pain, nasal congestion, sore throat  Respiratory:  Was noted in HPI Cardiovascular: No Chest pain, palpitations, syncope  Gastrointestinal: No nausea, vomiting, diarrhea, weight loss  Genitourinary: No hematuria, no dysuria  Musculoskeletal:  Swelling/pain/redness right breast as noted in HPI Integumentary: No rash, pruritus, abrasions  Neurologic: Alert & oriented X 4, no weakness, difficulty speaking  Psychiatric: No anxiety, depression    Physical Exam Vitals & Measurements T: 98.4  °F   HR: 103(Peripheral)  RR: 20  BP: 114/75 SpO2: 96%  HT: 167.6 cm  WT: 90.909 kg     General: Alert and oriented, no acute distress.  Eye:  EOMI, normal conjunctiva.  HENT: Normocephalic,  normal hearing, moist oral mucosa, no scleral icterus  Neck: Supple, non-tender,  Lungs:  Diminished dependent regions not working hard to breathe 3 L nasal cannula .  Heart: S1/S2 noted, heart rate upper 90s during exam Abdomen: Soft, non-tender, non-distended, normal bowel sounds,  Musculoskeletal:  Swelling/erythema right wrist mild to moderate tenderness to palpation, extending to distal right forearm Skin:  No other gross rashes or lesions noted otherwise as noted above Neurologic: Awake, alert, and oriented X3, no focal deficits spontaneously moving all 4 extremities Psychiatric: Cooperative, appropriate mood and affect.    Assessment/Plan     Acute left wrist pain and swelling-suspicious for septic joint  - elevated inflammatory markers.  as noted orthopedic has evaluated patient emergency department.  Plan is to go to OR for washout.  - will hold antibiotics till washout, culture/sample can be obtained.  Discussed with nursing not start antibiotics till surgical intervention.  Patient is NPO  - continue analgesics will hold off on NSAIDs with history of CHF  Hypoxia  Possible fluid overload/pneumonia  Possible COPD exacerbation-mild  - initial confer in for COPD exacerbation.  Sbreathing treatment in emergency department 3 L oxygen continue pulse ox titrate as tolerated.  - p.r.n. neb treatments.  Chest x-ray concerning for infiltrate however was very recently admitted for COVID-19 neumonia may be residual findings    Is on broad-spectrum antibiotics which should cover.  No wheezing on auscultation.  Monitor  - history of CHF some fluid noted though no coarse sounds or increased work of breathing.  Holding IV fluids consider Lasix status post procedure.    Suspect may be more related to fluid status.  History of heart failure -with preserved ejection fraction?  - last echo from 2019, however documented from PCPs note. Chest x-ray as noted, monitor fluid status closely consider Lasix as needed.  Low-sodium diet.  Tele.  Recent COVID-19 pneumonia  - reportedly received vaccine March 2021. However reports being admitted in August as this year for respiratory symptoms with discharged only 1 week previously.    Re swab as needed.  Acute respiratory Management as noted above comfortable not working hard to breathe.   CAD on aspirin  - no chest pain baseline EKG obtained.  Restart home medications as appropriate  OSA on CPAP  Hypertension  Dyslipidemia  - continue home medications as reconciled and is appropriate.   Prophylactic measure  -SCDs in setting of procedural intervention   Code status  -full code   Greatly appreciate Orthopedics assistance and recommendations with this case   Management as noted above based on presentation I believe patient will require greater than 2 midnight stay for evaluation treatment of underlying condition.  Further course based on findings.   Face-to-face encounter 3:05 p.m. on 09/10/2021       Discharge Diagnosis Acute left wrist pain and swelling-suspicious for septic joint  - elevated inflammatory markers.  Based on findings ortho was consulted, status post I&D per Ortho on September 10th  - blood and tissue sample collected for culture.  Cultures negative to date, vanc/Zosyn was initiated.  Possible Recurrent episode, have discussed for input, who recommended 3 weeks of Levaquin instead of doxycycline and following up with ID clinic in 1 week for further antibiotic management.  Clinically his signs and symptoms improved, patient work with orthopedic and therapy both cleared him for discharge.  Skilled nursing was offered to patient however he declined and wished to return home with home health.  Hypoxia  Possible fluid overload/pneumonia  Possible COPD exacerbation-mild  -initially on 3 L on admission however room air at time of examination this a.m., no coarse sounds or wheezing appreciated.  Room air. Chest x-ray concerning for infiltrate however was very recently admitted for COVID-19 pneumonia may be residual findings    PCR is positive so will keep on contact/droplet precautions.  Was quickly weaned down to room air with Re re-initiation of patient's home Lasix, did not require any supplemental oxygen otherwise during course of admission. No respiratory distress endorse.   History of heart failure -with preserved ejection fraction?  - last echo from 2019, however documented from PCPs note. Restart home Lasix monitor.  Did not appear grossly fluid overloaded.  Recent COVID-19 pneumonia  - reportedly received vaccine March 2021. However reports being admitted in August this year for respiratory symptoms with discharged only 1 week prior to admission.  Precautions as noted otherwise no respiratory symptoms prior to discharge.  Recent cardiac arrest  -per chart review 3 weeks ago when patient was admitted COVID.  Echo was noted no current symptoms, no chest discomfort on tele.  CAD on aspirin  - no chest pain baseline EKG obtained.  Restart home medications as appropriate   OSA on CPAP  Chronic steroids  History of prostate cancer on treatment  Hypertension  Dyslipidemia   All ED and RTC precautions provided to patient, endorses understanding and agreement with plan as outlined above. PCP follow-up within 7 days of discharge, id follow-up as discussed.  Hospital Course  Procedures (09/10/2021 11:46  Forearm Right) IMPRESSION:   Degenerative changes at the wrist with no acute fracture.  [1]  (09/10/2021 11:46  Wrist Routine Right) IMPRESSION:   Degenerative changes and sclerosis in the lunate with ulnar positive variance suggesting ulnar abutment syndrome.   [2]  Patient is a pleasant 81-year-old male with past medical history of BPPV, CAD, CHF, hyperlipidemia, hypertension, obesity, recent history of COVID-19 pneumonia, history of COPD comes in with chief complaint right-sided risk swelling/pain.  Clinical picture started this past 2 to stay patient suddenly started noticing swelling discomfort of his wrist swelling and redness started to increase and progressed approximately a from right wrist was not improving so came into the emergency department for further evaluation. In ED lab work demonstrated no significant leukocytosis, however there is elevation of ESR, CRP. Imaging of right wrist demonstrated degenerative changes with no fracture.  Forearm imaging with sclerosis in the lunate will out ulnar positive variance.  Patient also developed some hypoxia/shortness of breath well in ED placed on 3 L oxygen breathing treatments for possible mild COPD exacerbation.  Chest x-ray was ordered demonstrated pulmonary vascular congestion and patchy airspace disease in bilateral lungs concerning for pulmonary infiltrate.  In emergency room, patient received analgesics, IV fluids, breathing treatment.  At bedside lying comfortably in bed currently denies lightheadedness, dizziness, chills, fevers, nausea, vomiting, diarrhea, chest pain, palpitations, abdominal pain, paresthesia or swelling of extremities, dyspnea.  Pain discomfort in right wrist as well controlled after analgesics. Of note patient reports he was admitted last month for COVID-19 pneumonia was discharged only last week to home without any supplemental oxygen.  Reports he has been compliant with his home medications as prescribed though did not take his meds this morning.  He denies being on blood thinners.  He does report previous history of left wrist pain/joint infection which required washout hospitalization and antibiotics.  Otherwise denies alcohol, marijuana/recreational drugs, takes over-the-counter vitamins.  Family history otherwise reviewed and noncontributory to presenting finding.  Physical Exam Vitals & Measurements T: Warm(Skin)  TMIN: 35.9  °C (Temporal Artery)  TMAX: 36.3 °C (Tympanic)  HR: 71(Peripheral)  RR: 16  BP: 137/69 SpO2: 95%     General: Alert and oriented, no acute distress.  Eye: normal conjunctiva.  HENT: Normocephalic,  normal hearing  Lungs:  Room air diminished in lower lung fields not working hard to breathe Heart: S1/S2 noted, rr Abdomen: Soft, non-tender, non-distended,  Musculoskeletal:  Right forearm in rest in dressing, interval improvement in swelling appears clean dry intact otherwise Neurologic: Awake, alert, and oriented X3, spontaneously moving all 4 extremities Psychiatric: Cooperative, appropriate mood and affect   Home Medications (22) Active  Advair Diskus 250 mcg-50 mcg inhalation powder 1 Puffs, Inhalation, BID (Twice Daily)  aspirin 325 mg, PO, Daily (Once Daily)  ASV machine and supplies See Instructions  atenolol 50 mg, PO, Daily (Once Daily)  atorvastatin 40 mg, PO, HS (At Bedtime)  AUTO-CPAP FOR SEVERE OSA See Instructions  calcium citrate 200 mg, PO, BID (Twice Daily)  diclofenac 1% topical gel 4 gm, Topical, QID (Four Times Daily)  furosemide 20 mg oral tablet See Instructions  lactobacillus rhamnosus GG oral capsule 1 Cap, PO, BID (Twice Daily)  levoFLOXacin 750 mg oral tablet 750 mg = 1 Tab, PO, HS (At Bedtime)  morphine 15 mg/8 hr oral tablet, extended release 15 mg = 1 Tab, PO, Q8Hours  nitroglycerin 0.4 mg, PRN, Sublingual, Q5Min-Interval  Norco 5 mg-325 mg oral tablet 1 Tab, PRN, PO, Q4Hours  potassium chloride 20 mEq oral tablet, extended release See Instructions  predniSONE 5 mg oral tablet 5 mg, PO, BID (Twice Daily)  ProAir HFA 90 mcg/inh inhalation aerosol 2 Puffs, PRN, Inhalation, QID (Four Times Daily)  Spiriva 18 mcg inhalation capsule 18 mcg = 1 Cap, Inhalation, Daily (Once Daily)  Tylenol Extra Strength 500 mg oral tablet 500 mg = 1 Tab, PRN, PO, Q6Hours  Vitamin B Complex with C oral tablet 1 Tab, PO, Daily (Once Daily)  Vitamin D3 2,000 International Units, PO, Daily (Once Daily)  Zytiga 250 mg oral tablet 1,000 mg, PO, Daily (Once Daily)  Discharge Plan Management as noted above       Patient Discharge Condition Fair  Discharge Disposition Home with VNA  Discharge Instructions  Discharge Instructions 10_8_16 (Custom)  Antimicrobial Stewardship Patient Education (Custom)  Septic Arthritis   Follow-Up       With  When  Contact Information        Orthopaedics Within 2 weeks       Additional Instructions:          Internal Medicine Within 7 to 10 Days       Additional Instructions:         Home Health);      Additional Instructions:         Family Practice In 0 days       Additional Instructions: