COVID Breakthrough Case  Moderna Dose 1 2/20/21 (023M20A) Moderna Dose 2 3/17/21 (026A21A) COVID Positive 10/18/21  10/18/21: -Patient is a 75 yo male with medical history of atrial fibrillation on anticoagulation, CAD, COPD on 8L home oxygen , HTN, HLD, Pulmonary HTN , pulmonary nodules -Patient is presenting because of worsening SOB which started earlier today . He couldnt not take deep breaths -He was noted to be saturating 69% when he arrived for pulmonary rehabilitation on 8L NC oxygen . -He has a history of severe pulmonary HTN. He says he was refused Lung transplant because they did not have the expertise and recommended he goes to another facility. He is very meticulous about his medical care. He checks his pulse oximeter very closely and regularly and usually engages in deep breathing exercises to improve oxygenation -He is chronically SOB with exertion because of pulmonary HTN and usually takes things slow -He is a former smoker. He is not an alcoholic -He is COVID vaccinated -In the ER he was in moderate respiratory distress. He had increasing oxygen reequirements and was eventually put on BIPAP with improvement in oxygenation. He was initially weaned down simple mask but this was temporary and he again required BIPAP. He received total 60mg IV lasix in the ER prior to transfer to hospital.  -CXR showed extensive bilateral predominantly peripheral infiltrates which appear to be new and superimposed on chronic interstitial fibrosis and emphysematous changes when correlating with outside chest CTs. This may represent acute viral pneumonia superimposed on chronic lung disease.  Atypical pattern of pulmonary edema is also possible.  There does appear to be a small right pleural effusion. -Labs were remarkable for PH 7.49, pCo2 25, pO2 38 on oxymask, proBNP 1545, Mg 2.7 , LFT wnl, T bili 2, glucose 127, trop < 0.01, Hb 13.4, normal wbc, rapid covid negative -During my encounter patient was feeling much better , was not SOB and able to complete sentences. He was off BIPAP and on 10L oxymask  10/27/21: Patient is 75-year-old male with past medical history of chronic hypoxic respiratory failure on a L oxygen at home, advanced COPD/emphysema, pulmonary hypertension, atrial fibrillation anticoagulated with Eliquis, coronary artery disease status post multiple stents, hypertension and dyslipidemia.  He presented to the emergency room with a complaint of shortness of breath. Noted to be desaturating as low as 69% on his baseline oxygen requirement of a L per minute via nasal cannula. Upon evaluation at the ED, he was in respiratory distress. He was immediately placed on BiPAP.  Chest x-ray revealed extensive bilateral predominantly per E femoral infiltrate which was new which appear to be new and superimposed on chronic interstitial fibrosis and emphysematous changes when correlating with outside chest CTs or viral pneumonia. Pulmonary edema was also entertained.  For possible CHF exacerbation, patient was started with IV Lasix. Nasopharyngeal swab came back positive for COVID-19. Recent worsening of respiratory status was considered to be due COVID infection.  Patient is fully vaccinated for COVID-19. Dose of IV Lasix was decreased and patient was started treatment for COVID-19 with IV dexamethasone, remdesivir and Actemra for possible superimposed bacterial pneumonia, he received IV ceftriaxone and doxycycline. Pulmonary team was consulted and recommendations were followed.  Patient's respiratory status progressively improved.  On day of discharge, he was maintaining saturation on 8 l/min oxygen via nasal cannula which is his baseline.  However, he was noted to be desaturating with activity.  Patient reported that he normally tends to desaturate easily with activity. He was provided by oxygen Oxymizer with improved oxygenation with activity.  During his hospital stay, his blood pressure was noted to on the lower side.  His home medication insulin and fluids continue but calcium channel blocker felodipine 10 mg was held.  On day of discharge, both sildenafil and felodipine are being resumed.  Patient was instructed to monitor his blood pressure at home and possibly hold felodipine if systolic blood pressure greater than 110 mmhg.  Patient will follow-up with PMD in 1 week and pulmonary hypertension clinic at hospital as scheduled.  Patient has been cleared for discharge by Pulmonary team.