Age: 68.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Pyrexia, SARS-CoV-2 test positive, Sputum discoloured, Venous thrombosis
Clinical narrative: Hospitalized (9.13.21 - present);  Symptoms started week prior;  COVID-19 positive (9.13.21);  Fully Vaccinated Pt is a 69 y.o. male  who presents to hospital with difficulty breathing. The patient is known to have history of multiple comorbidities including chronic obstructive pulmonary disease, obstructive sleep apnea on CPAP, hypertension, pneumonia in the past, tobacco use, hypertension, and diabetes mellitus type 2. On September 9, 2021, the patient was presented to his primary care physician office because of increasing productive cough with poly phlegm, and increase of difficulty breathing.  At that time he did not have any fever.  Also the patient had some diarrhea at that time.  He was given a course of Zithromax.  However since then, the patient did not improve.  Instead he has been feeling feverish with productive cough, and more difficulty breathing.  He came back to the emergency department for evaluation.  The patient COVID-19 PCR rapid test came back positive.  The chest x-ray showed mild bibasilar hazy and streaky opacities right greater than left compatible with pneumonia.  The patient was hypoxic in the emergency department with oxygen saturation 84% on room air.  He has been requiring high-flow nasal cannula initially with FiO2 90% and later it went down to 35%.  The patient is being admitted to the hospital for further evaluation treatment. Assessment and Plan Medical Decision Making This is a 69 years old gentleman who was presented to the emergency department because of 5 days complaining of productive cough with yellow phlegm, difficulty breathing, and diarrhea.  On presentation he was hypoxic with oxygen saturation 85% on room air.  The patient is requiring oxygen supplement via high-flow nasal cannula.  The chest x-rays showed bibasilar infiltrations compatible with pneumonia.  The PCR rapid test for COVID came back positive. 1. Acute hypoxic respiratory failure.  Present on admission.  Associated with COVID-19 pneumonia and chronic obstructive pulmonary disease exacerbation.  The patient is requiring right now high-flow nasal cannula with FiO2 35%.  We will keep monitoring.  The patient is full code. 2. COVID-19 pneumonia.  Present on admission.  The patient is on dexamethasone and remdesivir.  Will re-evaluate in the morning.  We will do daily COVID-19 lab care set. 3. Chronic obstructive pulmonary disease exacerbation.  Present on admission.  The patient has already failed outpatient Zithromax orally.  We will continue breathing treatment.  Notes from 9.20.21: ASSESSMENT / PLAN:   Acute on chronic hypoxic respiratory failure Severe COVID-19 pneumonia s/p vaccination COPD exacerbation - Continue HFNC and titrate to maintain saturations of 90-94% - Continue Decadron; s/p Remdesivir - Maintain euvolemia and diurese prn -Antitussives prn, encourage IS use and prone  - Continue duonebs q 6h prn - Mucinex  - Dulera and spiriva and Singulair  **DDimer was increasing; no PE noted, small acute thrombus in the cephalic vein that does not require full dose anticoagulation. CTA does show PA dilation; likely c/w PAH.