COVID vaccine breakthrough case  Pfizer Dose 1 3/17/21 (EN6208) Pfizer Dose 2 4/14/21 (EW0153) COVID Positive 11/9/21  11/9/21: 73-year-old woman who presented with complaints of generalized weakness and diarrhea.  She reports insidious onset of symptoms approximately 4-5 days ago with daily diarrhea,  having 10-10 anti lose watery bowel motions daily.  She reports associated nausea and abdominal cramping, denies vomiting, fever or chills.  She denies any similar symptoms in household contacts, denies dietary indiscretions or recent travel.  She reports antibiotic use within the last 30-90 days.  She presented to the emergency department where laboratories remarkable for acute kidney injury, Hyperkalemia and lactic acidosis.  She has not had any further watery bowel motions since presentation to the emergency department.  She has been admitted to hospitalist services for further treatment and evaluation.  11/16/21: A 73-year-old woman with a history of chronic hypoxic respiratory failure on 3 L of home oxygen, chronic kidney disease, hypertension, hypothyroidism, type 2 diabetes mellitus, presented complaints of generalized weakness and diarrhea.  In the emergency room, patient was noted to have volume depletion with acute kidney injury and lactic acidosis and hyperkalemia which was corrected.  She was done IV fluids for hydration.  COVID-19 screen returned positive.  Chest x-ray done on presentation revealed diffuse airspace disease.  Patient was managed with IV dexamethasone, IV antibiotic therapy with ceftriaxone and azithromycin.  Pulmonary was consulted to assist with management.  She was started on Actemra and remdesivir.  She had worsening oxygen requirement, requiring up to 8 L of oxygen.  She had bradycardia rate remdesivir and this was discontinued.  Patient had resolution of diarrhea, resolution of lactic acidosis and improvement in acute kidney injury back to her baseline.  She has improved, has been weaned to 3 L of oxygen.  Patient assessed by Physical therapy with recommendations for skilled nursing facility.  Patient is being discharged to a skilled nursing facility.  11/26/21: A 73-year-old lady presented to the emergency room with complaint of generalized fatigue.  The patient reports that she was just discharged from Hospital yesterday.  Before yesterday on November 24.  On arriving home, she had a fall hitting her head. Today, she is experiencing weakness and has been unable to stand by herself since discharged from the hospital, and had had about 4 recent falls.  The patient denies shortness of breath.  She normally uses 2 L of oxygen at baseline.  She was treated for COVID-19 pneumonia and discharged 10 days ago after completing a course of remdesivir, steroid, dexamethasone,  as well as empiric antibiotic therapy.  She currently denied any chest pain.  11/30/21: Creatinine improved from 2.06 to 1.3, within baseline. UA is unremarkable.  Blood cultures negative.  COVID-19 positive.  CRP was 0.3.  Portable chest x-ray was reviewed. A 73-year-old lady presented to the emergency room with history of generalized fatigue, shortness of breath.  After thorough review, the patient was noted to be hypotensive, bradycardic, likely related to metoprolol.  The patient also was noted to have an AKI. The patient was hydrated.  Metoprolol was eventually discontinued as she also had a baseline of left bundle branch block.  The patient's condition has improved.  Her blood pressure has remained steady.  The patient, however, is deconditioned and will be discharged to skilled nursing facility for further conditioning.