COVID Breakthrough  Pfizer Dose 1 1/29/21 (lot not listed in online documentation system) Pfizer Dose 2 2/19/21 (lot not listed in online documentation system) COVID Positive 8/7/21  8/7/21: The patient is a 68-year-old male with systolic CHF, history of aortic valve replacement, COPD, hypertension, hyperlipidemia, sleep apnea, anticoagulated on Xarelto. The patient was recently treated and discharged to home after his stayed in the hospital for acute exacerbation of systolic CHF.  He thinks, starting from the day of last hospital,  fluid isbuilding  in his body with worsening bilateral leg swelling and fatigue.  He has intermittent dyspnea, orthopnea and paroxysmal nocturnal dyspnea.  The  patient claims that he is compliant with his medications.  He does not use any oxygen, BiPAP or any other breathing equipment.  He denies any cough, chest pain, fever or palpitation.  He has no wheezing.  In the emergency room patient was short of breath.  Heart rate 90, respiratory rate 22, pulse ox initially was 89% on room air that improved to 90% on 3 L, blood pressure was 140/101. Blood work shows sodium 136, potassium 3.9, BUN 9, creatinine 0.8, proBNP 9037, troponin negative, hemoglobin 11.24. CT of the chest is showing bilateral interstitial infiltrate improved on a edema pattern  8/26/21: The patient presented to the hospital on August 7 with left lower extremity swelling and generalized fatigue with episodes of cough and shortness of breath and body aches, he was hypoxic 89% on room air required  2-3 L of oxygen, chest exam show mild wheezing and crepitations, had lower limb pitting edema and he was fluid overloaded.  His labs show AKI which developed later into acute renal failure, had electrolyte disturbance including hypokalemia and hypomagnesemia.  His COVID-19 test PCR is positive, due to AKI patient was not candidate for antiviral therapy and the patient received dexamethasone IV, patient receive COVID-19 vaccine prior to infection.  The patient started on IV Lasix with worsen renal function, the nephrologist consulted and the patient started on Bumex drip then the patient developed acute renal failure, Foley cath inserted and the patient had obstructive uropathy.  The patient cardiac tele monitor show episodes of nonsustained V-tach with known underlying history of CAD status post CABG and TAVR.  The cardiologist consulted, patient started on beta-blocker then the patient developed bradycardia so beta-blocker held.  Patient also developed episodes of V-tach and started on amiodarone then taper down.  He was on Xarelto which is switch to Eliquis due to acute renal failure.  Patient developed HAP and was on Zosyn.  He only require 1-2 L of oxygen which taper down and till he did not require any oxygenation.  Patient had TTE show EF 30%, severe Lt and Rt atrial dilation, mild AS and functional prosthetic valve, indirect signs of moderate pulmonary hypertension.  CT angiogram chest and abdomen done and show the patient does not have pulmonary embolism and show the bilateral diffuse inflammation with mild abdominal ascites and cardiomegaly.  The patient had cardiac catheterization on August 24th with stent placement, he is on triple therapy aspirin, Plavix and Eliquis for a month then hold aspirin as per the Cardiology team recommendation. Hold Entresto due to acute renal failure.  The patient had tunneled the his cath placed for hemodialysis and had hemodialysis session, then his renal function improved and he did require hemodialysis, then his urine output and renal function improved and he did not require any more hemodialysis.  Patient had recurrent episodes of hypokalemia and hypomagnesemia that require replacement p.o. and IV.  The patient plan is to discharge him to skilled nursing facility, continue Foley catheterization and follow-up on repeated BMP and electrolytes, follow-up with the urologist within a week to evaluate his obstructive uropathy and possibly after that removing the Foley catheterization, follow-up with the nephrologist to re-evaluate his renal function and electrolytes and possibly adjusted the dose of Bumex, follow-up with the cardiologist to re-evaluate his CAD status post stent/heart failure and arrhythmia and readjust his medication as needed.  Follow-up with PCP to re-evaluate his general progression in health and coordinate the care between the specialists.