COVID Pfizer Vaccine Breakthrough Case  Pfizer Dose 1 2/9/21 (el3302) Pfizer Dose 2 3/9/21 (EN6199) COVID Positive 7/30/21  7/30/21: Patient is an 86-year-old male with history of paroxysmal atrial fibrillation on Eliquis, history of severe CAD s/p CABG x2 recurrent PTCA with intervention with most recent angiogram in July 27 with PCI to RCA and DES x2, history of COPD, diabetes mellitus, who is coming to the emergency department with a complaint of persistent shortness of breath and cough since Tuesday.  Patient had angiogram in Tuesday, Tuesday night he started having some shortness of breath, Wednesday his cardiologist changed Brilinta to Plavix due to concern of Brilinta induced dyspnea.  Patient's symptoms continued to get worse, he continues to have shortness of breath, nonproductive cough, reported some chills but no fever, his daughter is COVID-19 positive and he was in close contact with her recently. Symptoms started Tuesday, symptoms are progressive, patient received COVID-19 vaccine in February.   In ED, as low as 78% on room air, was placed on BiPAP initially then transition to OxyMask.  COVID-19 test came back positive. Creatinine 1.38, ALT 65, AST 104, lactic acid 4.9, lipase 53, troponin 0.09, WBC of 13.6 K, was given 1 dose of Rocephin and Zithromax.  8/15/21: As noted patient is a 86-year-old male came with complaints of persistent shortness of breath and cough, was admitted a short time before for CAD with angiogram with DES.  Few days after he got home started having symptoms as noted progressively got worse came into the emergency department for evaluation especially as he had close contact with family members who were positive for COVID-19. Patient reportedly received COVID-19 vaccination in February, on arrival to ED was tested and was positive. Patient was initially hypoxic to 70% on room air was placed on BiPAP and then transition to OxyMask.  Empirically started on antibiotics Rocephin/azithromycin, steroids, remdesivir.  Was already on Eliquis.  Pulmonology was consulted, pharmacy was made were breakthrough COVID infection, along with possible pneumonitis and COPD exacerbation.  He was transferred to ICU for closer monitoring.  Pulmonology also recommended Actemra, Lasix, breathing treatments which patient received.  Responded to treatment and oxygen was gradually weaned down and patient was transferred from ICU to medical/cardiac floor.  During course of admission patient also had a decrease in heart rates dropping down to 30s, patient was asymptomatic however review of tele/EKG demonstrated Mobitz type 2 heart block with 2-1 block.  EP was consulted and patient was taken to procedure lab for pacemaker placement, tolerated procedure well, and heart rates appropriate.  Patient finish course of antibiotics, Solu-Medrol was wean down oxygen at 2 L per pulmonology recommendation was switched to p.o. prednisone with taper on discharge.  Patient had O2 walk evaluation prior to discharge will need 2 L at rest and 3 L at rest.  Patient also had Lantus with sliding scale during admission, elevated sugar suspect secondary to stress and steroid use.  Will discharge on Lantus with testing strips and glucometer, also placed on metformin. Will need q.i.d. checks at home and likely will need close titration per outpatient provider as steroid is tapered down.  COVID safe for home program.  Passed therapy goals. Foley was removed past trial of voiding.