9/22 Per Patient: received the 2nd Pfizer vaccine Thursday, 9/9/21 at 1900. By Friday he was feeling bad and on Monday 9/13/21 he was very SOB and had to come to the ED. 9/14 Per ED: Patient is a 71-year-old gentleman comes in with shortness of breath, fatigue and dyspnea on exertion.  Patient states he had COVID back in January of this year.  States he spent 6 months in the hospital.  His DVT to self hot a walk.  He states that since last week and not been feeling well and felt like he was coming down with something.  He states he went and had his 2nd COVID vaccination this past Thursday since then has been feeling very bad.  The duration is constant.  The onset progressive.  The intensity moderate.  The quality as above.  This is single episode.  No radiation.  Nothing makes it better or worse.  No other associated symptoms.  Patient arrived with a fever. 9/14 Per ID: 1.  Neutropenic fever:  Appreciate Dr. note.  Neutropenia thought to be due to to vaccine.  Per pt, has not received recent chemo.  Cbc from 8.9 shows a wbc of 5, ANC of 3800 and plts of 163.  D/w Pharmacy.  Not a known side effect.  Will report this to VAERS  For now continue cefepime + doxy. 2.  Possible PNA:  Chest CT reviewed.  Old changes, but possible new infiltrates.  Continue cefepime/doxy 3.  H/o COVID-19 4.  CLL   5.  Sacral ulcer:  Much improved.  Continue local care 9/17  Per ID: 1.  Neutropenic fever:  Appreciate Dr. note.  Neutropenia thought to be due to to vaccine.  Per pt, has not received recent chemo.  Cbc from 8/9 shows a wbc of 5, ANC of 3800 and plts of 163.  D/w Pharmacy.  Not a known side effect.  Will report this to VAERS  For now continue cefepime + doxy- upon discharge can convert to Levaquin 750 mg every 48 hours x 3 doses.  WBC improving , hemoglobin low 7.0- to receive transfusion today  2.  PNA:  Chest CT reviewed.  Old changes, but possible new infiltrates. Continue cefepime/doxy-- > po Levaquin upon discharge.  procal better today. Initial value may not have reflected the peak.   3.  H/o COVID-19 4.  CLL   5.  Sacral ulcer:  Much improved.  Continue local care 9/17 Per Oncologist: Pancytopenia/Acute illness - New and acute onset - I suspect secondary to acute reaction to COVID vaccine and inflammatory cascade  process but secondary to infectious process also possible  - No evidence of lymphocytosis with WBC differential - Will hold off on G-CSF support due to increase theoretical risk of neutrophil activation and lung inflammatory process  -  No evidence of b12 or folate deficiency - Counts seem to be slowly improving with increase in ANC and PLT count now normalized.  Hgb lacking behind somewhat.  Patient complaining of marked fatigue.  Will transfuse 1 unit of PRBC today  CLL - RAI stage II with complex karyotype (trisomy 12, deletion 13q, and 11q deletion) - Diagnosed in July 2019 - Enrolled in Clinical trial at medical. EA9161.  Ibrutnib/Venetoclax/Obinotuzumab - Treatment has been on hold since initial admission for critical COVID in end of January 2021 - Imaging studies have indicated partial response to therapy with no indication to resume therapy.  Patient was last seen at medical in August 2021 at the time WBC was 5.0/Hgb 10.1/PLT 163 with no absolute lymphocytosis  PNA - Covered with cefepime and doxy - Afebrile now  Hx of CAD - Has hx of CAD s/p PCI and stent placement in May 2019  Respiratory failure - Now resolved -  Tracheostomy has been removed - has required intervention for tracheal stenosis  COVID PNA in January 2021 -  Prolonged hospital stay with respiratory failure and trach and peg placement and need for renal replacement therapy - Patient is now s/p COVID vaccination