Patient admitted 7/26/2021 for substernal chest pain, Vaccinated 3/31/2021, tested positive for COVID 7/26/2021 Discharge 8/4/2021 to home  Report breakthrough COVID infection requiring hospitalization  Allergies (drug/food and reaction): Latex, PCN  Date of Vaccination:_3/3_/2021 and 3/31/2021 Dose:  2 Vaccine Manufacturer: _Moderna Lot #: 022M20A (first dose) Clinic Administering Vaccine: Unknown Injection site: Rt deltoid  Description of event/reaction: Breakthrough Covid infection requiring hospitalization  Date of Clinic Visit or Hospitalization: 7/26/2021 Reason for clinic visit or hospitalization: Saddle PE with resp fx COVID-19 positive test result: Yes; if Yes, date 7/26/2021 Plans to monitor (include medications if prescribed): On dexamethasone as not sure if resp fx is due to PE or COVID.   Patient is a 64 y.o. male with past medical history significant for Gout, OA, diabetes mellitus type II, HLD, HTN, and hypothyroidism who presented to UK GSH ED with chief complaint of 1 and a half week history of chest pain. Per report, the patient first presented to an outside hospital on 7/16, where he subsequently tested positive for COVID-19. He does endorse receiving his second dose of the COVID-19 vaccination in March. Additional reported symptoms include generalized weakness, substernal chest pain with intermittent coughing, poor PO intake, shortness of breath which is worsened on exertion, and fatigue. The patient states that although he was officially released from quarantine today, he has still been feeling poorly with his symptoms not improving. He denies diarrhea, vomiting, productive cough, fever, chills, or any other complaint at this time.  CT PE today showed extensive right and left pulmonary emboli, ground-glass opacities in the right upper and middle lobes which is suggested to be infectious or inflammatory (likely in part due to infarcts), and basilar atelectasis with slightly more nodular opacity in the right base that may reflect a degree of concomitant aspiration. Upon examination today, he is in no acute distress and is hemodynamically stable and afebrile. Hospital medicine has been consulted for admission of this patient for further evaluation and management of this patient's clinical presentation.   1. Extensive pulmonary emboli and saddle pulmonary embolus without right heart strain  - CT PE today shows extensive pulmonary emboli throughout right and left pulmonary arterial branches including a saddle embolus at the main right and left pulmonary artery bifurcation. Confluent groundglass opacities in the right upper lobes bilaterally most marked in the right upper lobe and the right middle lobe. Dependent atelectasis. More patchy nodular opacities in the right lung base. - CXR additionally shows that the lungs are hypoinflated. There is scattered opacifications in the bilateral lungs. There is perihilar opacification which may be prominence of the pulmonary vasculature versus lung disease. - Patient has been saturating at 90%-95% on 2L NC; no history of lung pathology - Is in no respiratory distress at this time, however does report substernal chest pain with clearing throat and coughing, dyspnea on exertion  PLAN - Continue therapeutic lovenox   - Continue to monitor oxygen saturations, hard telemetry    2. COVID-19 pneumonia with new oxygen requirement  - Initially diagnosed on 7/16; additional positive test today in ED - Patient reports symptoms including fatigue, substernal chest pain with cough, dyspnea worsened on exertion, and generalized weakness - Denies productive cough or respiratory distress  - Has been saturating 90%-95% on 2L NC supplemental oxygen PLAN - Will initiate dexamethasone as cannot rule out COVID-19 related hypoxia vs. sequela of extensive PE's - Make contact with IPAC tomorrow in order to continue or discontinue isolation protocol  - Supplemental oxygen per nursing with goal saturation of >92%  - Incentive spirometry to be encouraged per nursing hourly    3. Osteoarthritis of knees with chronic steroid use  - Patient does take prednisone 20mg  - Per most recent orthopedic office visit, patient will eventually need total knee arthroplasties PLAN - Will hold with preference for decadron in setting of possible COVID-19 hypoxia  - Oxycodone started PRN for pain   4. Diabetes Mellitus Type II  - Patient takes metformin outpatient for management  - High glucose today 145  PLAN - Will hold metformin while inpatient with preference for SSI and FS glucose monitoring    5. Hyponatremia  - Sodium today 134 - Likely secondary to recent poor PO intake given patient states he gets "tired" when trying to eat  PLAN - Encourage PO intake  - Repeat labs in AM   Chief Concern, Brief History of Present Illness, and Hospital Course Hospital course by problem list: # Extensive pulmonary emboli and saddle pulmonary embolus without right heart strain  - Patient has been stable saturating at >92% on 2L NC - HDS PLAN: Switch to Rivaroxaban 08/03 Ambulatory pulse Ox today (08/03): 85-87% after 2 minute walk test on 8/3.  However, the subsequent day a repeat ambulatory pulse ox that he was done and the patient was not noted to be hypoxic and was subsequently discharged home on rivaroxaban.     # SARV COV 2/ COVID 19 INFECTION - Initially exposure 7/15 with Antigen negative on 7/18 but later positive Covid antigen on 7/20 at Urgent care. Positive PCR on 7/26  PLAN: Dexamethasone x 10 as cannot rule out COVID-19 related hypoxia vs. sequela of extensive PE's.  Supplemental oxygen per nursing with goal saturation of >92%  Incentive spirometry to be encouraged per nursing hourly  Patient to complete dexamethasone at home with PPI to complete treatment for possible GI bleed.  Patient is advised to hold off on taking his home dose of steroids that he takes as needed for gout flares.    # Suspected GIB with  Melena x 2 and 2 gm hgb drop  - Hgb 15.4 on admission and now 8.4 (Likely patient had GI bleed + corrected dehydration) PLAN: Prior GI consult noted. No evidence of bleeding GI decided not to proceed with EGD On PPI BID po and will plan to proceed with x8 weeks Rx    # Thrombocytosis  - reactive and due to steroids/acute illness - Appreciate Heme rec - JAKS2  pending at the time of discharge. At the time of completion of this document it is noted to be negative.    # Suspected ABLA however no overt signs of acute recurrent bleeding - will continue to monitor    # Leukocytosis with no fever - reactive and due to steroids/acute illness    # Chronic Steroid Dependance - States he takes prednisone intermittently for gout (usually needs it once a month for a week's duration for gouty arthritis flare)