COVID Vaccine Breakthrough Case  Pfizer Dose 1 2/26/21 (EN6203) Pfizer Dose 2 3/24/21 (ER2613) Pfizer Dose 3 11/18/21 (FH8028) COVID Positive 11/26/21  11/26/21: The patient is a 76-year-old female with past medical history atrial fibrillation on Eliquis, pacemaker, diastolic heart failure, and current tobacco use who presented to the ED today for weakness which had been progressing for the past 4 days.  Last night she fell 5-6 times however denies any loss of consciousness.  She has significant history of smoking 1 pack/day, and has had a chronic productive cough.  She is not on any supplemental oxygen at home, and does not have an official diagnosis of COPD.  She denies any chest pain or cough however does endorse some shortness of breath.   ED course: Per ED note, patient was initially saturating 87% on 6 L which improved to 94% with a DuoNeb treatment. BP 95/52.  Labs notable for WBC 14.44, hemoglobin 16.1, potassium 5.3, creatinine 1.41, ALT 36, AST 94, ALP 129, mg 2.7, lactate 4.0, pro BNP 5073, troponin 0.09.  EKG indicated ventricular paced rhythm, no change since 2020. CXR indicated mild pulmonary venous congestion.  CT head indicated no acute intracranial abnormality.  She was given a DuoNeb, Solu-Medrol, azithromycin 500 mg, ceftriaxone 1g, in addition to 2 L NS.  Patient continued to exhibit respiratory distress so was then placed on BiPAP for increased work of breathing without significant improvement with nebulizer.  Notably she also had 3 bouts of diarrhea while in the ED.  She improved significantly with use of BiPAP.  She was admitted for acute hypoxic respiratory failure secondary to COPD versus CHF.   Surgical history:  Pacemaker placed 2010  SH:  Smokes 1 pack/day FH: noncontributory  12/3/21: The patient is a 76-year-old female with past medical history atrial fibrillation on Eliquis, pacemaker, diastolic heart failure, and current tobacco use who presented to the ED today for weakness and falls.  ED course: Per ED note, patient was initially saturating 87% on 6 L which improved to 94% with a DuoNeb treatment. BP 95/52.  Labs notable for WBC 14.44, hemoglobin 16.1, potassium 5.3, creatinine 1.41, ALT 36, AST 94, ALP 129, mg 2.7, lactate 4.0, pro BNP 5073, troponin 0.09.  EKG indicated ventricular paced rhythm, no change since 2020. CXR indicated mild pulmonary venous congestion.  CT head indicated no acute intracranial abnormality.  She was given a DuoNeb, Solu-Medrol, azithromycin 500 mg, ceftriaxone 1g, in addition to 2 L NS.  Patient continued to exhibit respiratory distress so was then placed on BiPAP for increased work of breathing without significant improvement with nebulizer.  Notably she also had 3 bouts of diarrhea while in the ED.  She improved significantly with use of BiPAP.  She was admitted for acute hypoxic respiratory failure secondary to COPD versus CHF.   She was found to be COVID positive.  She received Actemra as well as 5 day course of remdesivir and Decadron. Cardiology was consulted due to elevated troponin, troponin was trended, elevation thought to be secondary to infection.  No intervention was performed, recommended outpatient ischemic workup.  D-dimer was found to be elevated, CT chest negative for PE.  Eliquis as was increased to 5 mg b.i.d. for more adequate DVT prophylaxis. She was diuresed with IV Lasix per Cardiology.  Oxygen requirements gradually decreased, she was transitioned to room air however required supplemental oxygen not on oxygen walk test.  Order was placed so she could have home O2. She did have significant anxiety during this hospitalization, her home lorazepam was continued.  She also had a Foley catheter in place for a short period of time, after this was removed she was able to urinate without difficulty. Patient does have history of recurrent UTIs, urine culture was obtained and was negative.  At time of discharge she was feeling much improved, vitals were stable aside from as a O2, patient had adequate help at home and felt comfortable returning.  She will have visiting nurse at discharge.