Hospitalized 2.26.22 - PRESENT (currently in ICU); COVID-19 positive; Fully Vaccinated PLUS Booster Admitted 2.26.22 CHIEF COMPLAINT: Acute on chronic respiratory failure with hypoxia and hypercapnia (HCC)  HPI: 61 y.o. vaccinated male, active smoker, ESRD (T/R/S) chronic hypoxic, hypercapnic (pCO2 60s) respiratory failure, pulmonary htn, chronic diastolic dysfunction, insulin dependent T2 diabetes presented hypoglycemic (50 to EMS) and altered after having low PO intake, fatigue and 8 days of missed dialysis after testing positive for COVID-19 a week ago. Initial POC K 8.5, treated, glucose responded to D10 but became obtunded and intubated in the ER with acute on chronic respiratory hypoxic, hypercapnic respiratory failure, acute on chronic diastolic dysfunction and ESRD. Found to have polycythemia, hgb 22, new since December 2021. Monoclonal gammopathy is on his problem list. ASSESSMENT / PLAN:  61 y.o. vaccinated male, active smoker, ESRD (T/R/S) chronic hypoxic, hypercapnic respiratory failure, pulmonary htn, chronic diastolic dysfunction, insulin dependent T2 diabetes presented hypoglycemic (50 to EMS) and altered after having low PO intake, fatigue and 8 days of missed dialysis after testing positive for COVID-19 a week ago. Initial POC K 8.5, treated, glucose responded to D10 but became obtunded and intubated in the ER with acute on chronic respiratory hypoxic, hypercapnic respiratory failure, acute on chronic diastolic dysfunction and ESRD. Found to have polycythemia, hgb 22, new since December 2021. Monoclonal gammopathy is on his problem list. Assessment and Plan COVID-19 Overview Vaccinated 3/11/21, 4/1/21, 10/14/21 Symptom onset ~ 2/19 Positive 2/26/22   Assessment & Plan Noncontrast chest CT to evaluate for COVID pneumonia Check DDimer If elevated, BUE/BLE dopplers If evidence of possible COVID pneumonia on CT, will start steroids Remdesivir contraindicated with his renal disease Acute on chronic respiratory failure with hypoxia and hypercapnia (HCC) Assessment & Plan Due to pulmonary edema on baseline diastolic dysfunction, WHO group 2 and 3 pulmonary hypertension, COPD Also diagnosed with COVID a week prior, positive on today's PCR and may be playing a role CXR 2/26 w/enlarged PAs, vascular congestion, unable to differentiate a pneumonia in the bilateral lower lobes 7.14/94/63 on bipap, became obtunded in ER and intubated Intubation date: 2/26/22  Progress Note from 3.7.22:  ASSESSMENT / PLAN: * Acute on chronic respiratory failure with hypoxia and hypercapnia (HCC) Assessment & Plan Due to pulmonary edema on top of baseline chronic diastolic heart failure and WHO group 2 and 3 pulmonary hypertension, +/- component of COPD and/or component of pneumonia Pt also COVID positive, with symptoms x 1 week and positive PCR test 2/26 - however, not felt likely to be playing a role in current state of respiratory failure (discussed below) Intubated 2/26/22. Extubated 3/2/22.  Now on BIPAP 20/8. Despite poor seal with BIPAP mask, blood gases do improve with BIPAP. Will check a blood gas after completion of HD today. If improved, will trial him off BIPAP and repeat a blood gas a few hours afterwards. He should sleep on BIPAP tonight.  - continue BIPAP.  - HD today for volume removal Pneumonia Assessment & Plan Treated for CAP. Sputum cultures positive for Corynebacterium striatum. Completed 7 day course of ceftriaxone and 10 days of vancomycin today     COVID-19 Overview Vaccinated 3/11/21, 4/1/21, 10/14/21 Symptom onset ~2/16 Tested positive via home test 2/18 Seen in urgent care 2/23, discharged home as he was doing well Positive PCR test 2/26 Film array 2/28 negative, including negative COVID PCR Strep and legionella urine Ag's negative   Assessment & Plan CT findings demonstrate bibasilar consolidations, LLL>medial RLL, more suggestive of bacterial pneumonia vs atelectasis than COVID-related infiltrates. No obvious GGO consistent with typical COVID pneumonitis. Clinically, he has improved fairly quickly with positive pressure mechanical ventilation, diuresis/hemodialysis, and empiric abx, suggesting that COVID is not likely responsible for his respiratory failure and perhaps an incidental finding.   He was previously treated with solumedrol 125 mg x 1. Steroids not continued. Will continue holding further steroids for now, unless he manifests clinical worsening. Remdesivir contraindicated with his renal disease