COVID Vaccine Breakthrough Case  Pfizer Dose 1 4/6/21 (ER8734) Pfizer Dose 2 4/28/21 (ER8729) COVID Positive 11/30/21  11/30/21: Patient is a 56 year old male with a past medical history of HFpEF, HTN, HLD, CKD stage 4, hypothyroidism s/p thyroidectomy, chronic back pain on opioids d/t spinal stenosis, peripheral neuropathy, depression, anxiety, chronic migraines, hypogonadism, gout, OSA, and seasonal allergies who presented to the ED for worsening exertional dyspnea.  For the past 5 days he has been feeling short of breath with exertion and while laying flat.  He has been propping himself up at night so he doesn't have to lay flat.  At baseline he is on 3L O2 after having ARDS from H1N1 pneumonia.  Patient follows with (pulmonology).  He has been increasing his oxygen use to 4L while ambulating.  In addition to his shortness of breath he has had more frequent migraines, a fever with a Tmax of 101, a productive cough yielding green-white sputum, and constant chest pressure.  He has been taking ibuprofen for his fevers and myalgias, last dose at 0600.   In the ED: Temperature was 100.1, saturating 96% on 3L O2 and was hypertensive 160/93.  Labs were remarkable for Glc 109, Cr 1.63, Lactic acid 1.5, VBG unremarkable and no leukocytosis. CXR showed underlying parenchymal scarring/fibrosis with no superimposed acute process or adverse change.  No medications or interventions were performed in the ED.   PMHx: As above  SHx: No new surgeries, as documented  Allergies: Reviewed, as documented  Medications: Reviewed with patient.  He was uncertain of the dose of his lisinopril.  Dose was found from chart review.  Family History: No new medical diagnoses within the family, as documented.  Social history: Former smoker for 35 years, approximately 40 cigarettes per day.  Rare alcohol use.  Denies recreational drug use.  Lives at home with two family members.  12/10/21: Patient is a 56 year old male with a past medical history of HFpEF, HTN, HLD, CKD stage 4, hypothyroidism s/p thyroidectomy, chronic back pain on opioids d/t spinal stenosis, peripheral neuropathy, depression, anxiety, chronic migraines, hypogonadism, gout, OSA, and seasonal allergies who presented to the ED 11/30 for worsening exertional dyspnea.  In the ED: Temperature was 100.1, saturating 96% on 3L O2 and was hypertensive 160/93.  Labs were remarkable for Glc 109, Cr 1.63, Lactic acid 1.5, VBG unremarkable and no leukocytosis. CXR showed underlying parenchymal scarring/fibrosis with no superimposed acute process or adverse change.  No medications or interventions were performed in the ED.  He tested positive for COVID.  He was started on remdesivir and dexamethasone per standard COVID protocol.  Patient developed an AKI, due to history of nephrectomy nephrology was consulted.  Remdesivir was discontinued.  Medications were renally dosed.  He was diuresed.  He was placed on daily p.o. Lasix advised to follow-up with Nephrology outpatient.  Pulmonology was also consulted who ultimately recommended a steroid taper.   During his hospitalization imaging did reveal an incidental adrenal nodule which will need follow-up and further workup in the outpatient setting, particularly with his history of various cancers.   Patient's symptoms did slowly improve, oxygen requirements returned to baseline, vitals were stable.  He was agreeable to discharge to home with family care.