COVID Breakthrough Case  Pfizer Dose 1 3/17/21 (EP7534) Pfizer Dose 2 4/7/21 (ER8729) COVID Negative 9/30/21 COVID Negative 10/8/21 COVID Positive 10/13/21  9/30/21: Patient is a 91-year-old female with past medical history of Alzheimer's dementia, CAD, CHF with decreased ejection fraction of 9%, history of recent PE, history of CKD, history of CVA, hyperlipidemia, hypertension, spinal stenosis of lumbar region, recent humeral head fracture who was sent from nursing home with  shortness of breath. History is obtained from medical records and daughter at the bedside.  It appears that patient has been having some intermittent shortness of breath for the past few days. Since the last discharge patient has been on 2 L nasal cannula.  This morning 2:00 p.m. patient has not received a call reporting that patient's breathing has gotten patient was brought to the ED.   In the ED temperature 98.1°, heart rate 113, RR 32. Patient was found to be hypoxic and was placed on BiPAP 40%.  His CT chest showed chronic PE.  Chest x-ray showing emphysema.  Lab work significant for ALT 37, AST 41, ALP 101, T bili 0.3, proBNP 3900, troponin 0.15, VBG pH 7.32, pCO2 80, bicarb 42. WBC 6, hemoglobin 8.7, INR 1.4, D-dimer 0.58.  COVID-19 antigen negative.  10/23/21: As noted patient initially came in with shortness of breath, Solu-Medrol breathing treatments Lasix.  Noted have decubitus ulcer as well also also in back of he will was .  She was on Eliquis was held in anticipation of surgical intervention.  General surgery for debridement of unstageable decubitus ulcer sacrum stage II decubital ulcer both ischia and unstageable ulcer of left heel.  While patient's Eliquis was held and was on heparin she did develop a GI bleed as well, anticoagulation was discontinued.  GI was consulted findings of stomach suggestive of gastritis and duodenitis.  Subsequently during course of admission patient started to have hemorrhaging/bleeding from debrided sacral decubitus ulcer. Again anticoagulation was discontinued patient was transfused with RBC and FFP.  Patient was transferred to ICU, also received protamine and General surgery evaluated and repacked wound.  Stabilize in was moved back to medical floor.   Because of significant bleeding patient could not be anticoagulated, patient had chronic pulmonary embolism discussion for IVC filter was had with IR however deemed too high of a risk for placement.  Decision was made to the patient on aspirin.  Patient also had bouts of proctitis receive stool softeners and doxycycline which corrected appropriately.  Patient's p.o. intake was poor, refused NG, and with baseline dementia risks of pulling out.  General surgery was consulted to see if patient would be a candidate for PEG or G-tube and after discussion with family General surgery reports that patient is not a candidate for feeding tube.  Diet was attempted to be optimized with dietary assistance.  Palliative Care met with patient and family, wanted to continue aggressive care with full code status in spite of poor prognosis.  Dietary was continue low-dose Remeron added.  Will need longitudinal follow-up with surgery, dietary as outpatient. Will also have to discuss with outpatient providers on potentially restarting anticoagulation down the lying will have to discuss all risks and benefits with patient and family.