COVId Vaccine Breakthrough CAse  Pfizer Dose 1 4/29/21 (ER8734) Pfizer Dose 2 5/21/21 (EW0168) COVID Positive 12/5/21  12/5/21: patient is a 52-year-old female that presented via EMS to the emergency department during the overnight complaining of shortness of breath, cough with sick contacts. PMHx includes anxiety, tobacco use (45 pack-year-current), migraine history, degenerative lumbar spinal stenosis,  acid reflux, HLD, obesity, restless leg, type 2 diabetes (Ozempic, metformin, glipizide), history of vitamin-D deficiency.   On arrival to ED patient febrile, 101.5° F. patient requiring 10 L oxygen saturating 96%; patient became tachypneic, respirations 31 ultimately requiring BiPAP placement in the emergency department.  Blood pressures have been stable.  Noted 15 lb weight gain since previous hospitalization September 2021.  CMP showed patient hypokalemic 3.3, elevated BG 170, lactic acid 2.1, corrected calcium 8.7, microcytic anemia, hemoglobin 9.3 and COVID positive.  CXR supportive of diagnosis.  Patient received azithromycin, Rocephin, DuoNeb therapy, Solu-Medrol 125, 2 L NS.   In conversation with this patient over the course of the previous week she has noticed productive cough, shortness of breath that have progressively worsened.  She lives at home with her husband who was also sick at this time. Patient states that she has received 2 doses of the COVID vaccine, 2nd dose received May 21, 2021. Patient has not yet received influenza vaccine.  Patient has reproducible chest pain with coughing, patient denies radiation to left neck/shoulder or upper epigastric area.  Patient denies fever/chills at home, nausea/vomiting, abdominal pain. Notes suffered from diarrhea last week however that has abated.  Patient denies blood loss including melena, hematochezia and hematuria; patient not on blood thinners.   Due to patient's oxygenation requirements will be admitted to med pulmonary as an inpatient at this time.  12/9/21: patient is a 52-year-old female that presented via EMS to the emergency department during the overnight complaining of shortness of breath and cough. On arrival to ED patient febrile, 101.5° F. patient requiring 10 L oxygen saturating 96%; patient became tachypneic, respirations 31 ultimately requiring BiPAP placement in the emergency department.  Blood pressures have been stable. Noted 15 lb weight gain since previous hospitalization September 2021.  CMP showed patient hypokalemic 3.3, elevated BG 170, lactic acid 2.1, corrected calcium 8.7, microcytic anemia, hemoglobin 9.3 and COVID positive.  CXR supportive of diagnosis.  Patient received azithromycin, Rocephin, DuoNeb therapy, Solu-Medrol 125, 2 L NS.   She was admitted for acute hypoxic respiratory failure secondary to COVID-19 infection.  She received a 5 day course of remdesivir and dexamethasone.  She was anticoagulated with Lovenox 40 mg b.i.d. Due to hyperglycemia secondary to steroid use she will did require basal bolus insulin.  Throughout her course her respiratory status greatly improved.  Oxygen was able to be titrated down to 2 L at rest.  Wheezes, cough, and dyspnea improved. She was started on ferrous sulfate due to iron deficiency anemia.  Due to nasal congestion as well as a nasal sore from the nasal cannula she was started on Flonase and mupirocin ointment.  The day prior to discharge O2 walk test was performed, recommendation was 2L at rest and 4 L with ambulation.  She was kept one more day due to continued wheezing and dyspnea.  She is feeling much improved on day of discharge, lungs were clear and she was breathing comfortably on 2 L supplemental oxygen.  Repeat O2 walk test recommended 2 L at rest and 8 L with ambulation.  Patient was feeling much improved and desired to go home, she did have significant nasal congestion which was thought to be impairing her oxygenation with exertion. She was advised to stay 1 more day for further observation, patient declined.  Risks and benefits were extensively discussed, patient was enrolled in COVID safe at home and had a pulse oximeter to take home with her.  Stated she would closely monitor her her SaO2 in symptoms.  She is to call report to the ER for any worsening respiratory symptoms.  She will be discharged on a short course of steroids and anoro inhaler for COVID. She is to follow up closely with PCP. She verbalized understanding.