Hospitalized (9.24.21 - present);  COVID-19 positive (9.21.21);  fully vaccinated HISTORY OF PRESENT ILLNESS:   This is a 90-year-old female with a PMH of AFib on warfarin, hx of PE, hx of tachy-brady syndrome s/p pacemaker and mitral valve replacement, thoracic aortic aneurysm without rupture, CHF, chronic venous insufficiency, obesity, OSA on BiPap, GERD, trigeminal neuralgia and recent medical hx of suspected UTI and positive outpatient COVID test 9/21/21 who presents via EMS with a CC of shortness of breath.  On interview, pt is lying in a supine position and groaning in apparent pain.  She is partially oriented to situation and states she tested positive for COVID.  She states she received the Moderna vaccine several months ago.  She recognizes her daughter was at bedside.  She is unable to provide hx. Pt's daughter states was notified this week of a COVID-19 outbreak among residents.  She states the pt had increased urinary frequency this week and confusion yesterday and today, and was started on Bactrim for suspected UTI yesterday.  She also states the pt's warfarin was recently increased as her INR levels were too low.  She also states that her Entresto dose was recently increased by her cardiologist due to several weeks of shortness of breath.  She states the pt is a retired physician. She states the pt has sleep apnea and sleeps with a BiPAP nightly. In the ER the pt was found to be afebrile with hypoxia, stable on 2L O2.  CMP with Na+ 132, Cl-94, GFR 50, glucose 111, calcium 8.2, ALP 183, albumin 3.0, ALT 47, AST 23, otherwise WNL.  Procalcitonin and BNP WNL.  Total iron and iron saturation low, I BC and ferritin WNL.  INR 4.0, CBC with WBC 2.7, Hgb 10.7 MCV 83, platelets 152. CXR showed evidence of prior sternotomy, right-sided pacemaker, prosthetic valve, patchy bilateral airspace disease and central pulmonary vascular congestion.  Pt was given Decadron, 1L IVF bolus, and transferred for workup. Antibiotics -Bactrim 9/23-9/24 (outpatient) -azithromycin 9/24-present -Rocephin 9/24-present   Disposition:  Inpatient admission for acute respiratory failure with hypoxia 2/2 COVID pneumonia in a vaccinated elderly pt. Start Decadron and remdesivir.  Pt was also found to have INR 4.0, likely from recent Bactrim use and increase to warfarin dosage.  Pharmacy to dose warfarin.  Discontinue Bactrim.  Continue to treat urinary tract infection, start Rocephin and azithromycin for dual benefit.  Likely stay > 2 midnightsAcute respiratory insufficiency with hypoxia COVID 19 pneumonia -vaccinated with moderna 1/29-21 and 2/26/21 -per daughter, she received a letter stating there is an active covid outbreak, at least 10 residents positive for covid, 9 of which are vaccinated  -Symptom onset unclear as pt currently encephalopathic and also has suspected UTI -Outpatient + test 9/21 -Procalcitonin 0.13, BNP WNL -CXR patchy bilateral airspace disease with central pulmonary congestion, sense of prior right-sided pacemaker, sternotomy and prosthetic valve -start decadron and remdesivir -continuous pulse ox, wean to room air Urinary tract infection -increased frequency, outpatient UA positive, started on Bactrim 9/23, discontinue Bactrim given elevated INR -start Rocephin and azithromycin for dual benefit  Note as of 9.30.21:  ASSESSMENT / PLAN: Acute hypoxic respiratory failure COVID-19 pneumonia Tested positive on September 21st Chest x-ray showed patchy bilateral airspace disease On Decadron -Remdesivir complete Currently on 2L nasal cannula -wean Continues to have significant desaturation with activity Check BNP and CXR -may need to increase diuresis IS Patient fully vaccinated Urinary tract infection Urine culture grew E coli Rocephin completed