COVID Vaccine Breakthrough Case  Pfizer Dose 1 3/11/21 (EN6205) Pfizer Dose 2 4/2/21 (EN6198) COVID Positive 10/20/21  10/24/21: Patient is a 71 year old female with a past medical history significant for BA, CHF, COPD, CKD stage 3, type 2 diabetes, OSA, hyperlipidemia, hypertension, morbid obesity, anxiety.  The patient presents to the ED today with complaints of shortness of breath that began 5 days ago.  The patient's accompanying symptoms include weakness, fatigue, nausea, abdominal pain.  The patient denies any chest pain, fever, chills, diarrhea, rigors.  The patient is vaccinated against COVID-19.   Upon arrival to ED patient's temperature is 100.8°, heart rate 95, respirations 23, pulse ox 84% on room air, blood pressure 133/106.  The patient was placed on 4 L oxygen via nasal cannula to maintain O2 saturations greater than 90%. CT abdomen reveals no acute intra-abdominal process, diffuse hepatic steatosis and hepatomegaly.  CT chest reveals no PE, scattered bilateral areas of airspace disease involving all 5 lobes likely representing viral pneumonitis or multilobar pneumonia.  Patient's laboratory findings are significant for glucose 316, creatinine 1.12, AST 44, calcium 8.2, lipase 12 hemoglobin 11.7, D-dimer 0.61, COVID-19 positive.  Patient received DuoNeb x2, 500 mg IV azithromycin, 1 g IV Rocephin, 4 mg IV Zofran, 8 mg IV Decadron in ED.   Patient was seen and examined at the bedside in the ED. The patient is in mild respiratory distress, expiratory wheezing noted from the door.  Of note, the patient was admitted on 08/09/2021 and discharged on 08/13/2021 for acute COPD exacerbation, CHF exacerbation.  The patient was discharged to skilled facility until 09/03/2021.  11/5/21: Acute hypoxic respiratory failure - on 4 L NC O2 COVID-19 Pneumonia       --(+) 9/20       --vaccinated w/ Pfizer       --Remdesivir started 10/24 for 2 doses and then d/c'd due to no IV access       --Decadron started 10/25, which was gradually tapered      --Actemra 10/28  -  patient required supplemental oxygen, pulmonology was consulted on case and assisted.  With interventions as above respiratory status improved, patient was weaned to room air prior to disposition and headed O2 walk which patient did not qualify for supplemental oxygen.  She will be discharged with COVID safe for home and steroid taper as noted below.  Asthma Exacerbation  - on bronchodilators and steroids.  Steroids and breathing treatments were spaced out, steroids taper down.  As noted on room air prior to disposition will discharged on taper. Room air no wheezing prior to dispo.  DM, type 2, with hypoglycemia  - secondary to steroids.  Had some up and down readings secondary to this.  Steroids are being weaned down patient was maintained and manage with sliding scale and Lantus. Will continue q.i.d. blood glucose checks.  All precautions provided.  Will follow up with PCP within 7 days of discharge.  Possible CAP  -completed doxy, cultures remain negative.  Essential hypertension  - on amlodipine, losartan, hydralazine and Imdur   Hx CVA, with residual left-sided weakness - on Plavix  Morbid Obesity, BMI more than 40 kg/meter squared  PT, OT eval- patient refuse placement   All ED and RTC precautions were provided to patient she endorses understanding.  All COVID and isolation precautions were provided to patient endorse understanding and agreement with plan as outlined.  Follow-up with PCP within 7 days of discharge.