Chief Complaint   worse hypoxia, COVID  History of Present Illness     41 y/o female presenting to MICU for worsening hypoxia diagnosed with COVID PNA. PMHx of obesity, OSA (noncompliant w/ cpap), FVL, prior DVT, salivary gland CA (s/p RUL lobectomy). patient complains of sob, onset approximately 1 week ago, initially mild, constant, progressively worsening. Worse with coughing and walking, better with her night time oxygen. Associated with this she endorses some sinus congestion, cough, and mild dizziness, denies fever, chest pain, abd pain, no n/v/d/c.     Initially presented to hospital on 10/12, on HFNC, rapidly worsened to requiring high levels of oxygen - 75 - 90%, and thus transferred to MICU for higher level of care. Reportedly had a CT PE Chest at outside hospital which was negative for PE. Negative trop and BNP, CT chest showed bilateral ground glass opacities.   reportedly her entire family has COVID currently (husband and 2 kids).  Review of Systems     Complete ROS reviewed and is negative unless stated in the HPI  Physical Exam  Vitals & Measurements  T: 36.4 °C  TMIN: 36.4 °C  TMAX: 36.5 °C  HR: 102  RR: 18  BP: 123/85  SpO2: 90%  WT: 111.0 kg  BMI: 38.4      GENERAL: mild acute distress, afebrile, female mildly ill appearing  HEENT: NC/AT, mucus membranes moist, no rhinorrhea, HFNC in place  NECK: neck veins flat, supple  RESP: mildly labored with accessory muscle use, ctab, no obvious wheezes/rales/rhonchi  CV: sinus tachycardia, regular rhythm, no m/g/r, cap refill <3s, 2+ BLE edema,  ABD: NT/ND, soft, BSA  NEURO: Alert, oriented, purposeful, CNII-XII intact, strength 5/5 BUE/BLE, sensation intact  EXT: no clubbing, no cyanosis  SKIN: no ecchymosis, no petechiae, no purpura  PSYCH: cooperative and appropriate  Labs (last four charted values) HGB:         13.4   (10/12) WBC:         8.41   (10/12) PLT:         161   (10/12) Na+:         139   (10/12) K+:         4.4   (10/12) iMg:         0.45   (10/12) Phos:         3.3   (10/12) iCa:         1.15   (10/12) Cl-:         100   (10/12) CO2:         27  (10/12) BUN:         14  (10/12) Cr:         0.55   (10/12) PT:         13.3   (10/12) INR:         1.0   (10/12) LDH:         HEMOLYZED, unabl       (10/12) Alk Phos:         66  (10/12) AST:         HEMOLYZED, unabl       (10/12) ALT:        H  78  (10/12) T Bili:         0.37   (10/12)   CXR (10/12/2021):   IMPRESSION: 1.  Diffuse bilateral airspace opacities consistent with known COVID 19 pneumonia. 2.  Elevated right hemidiaphragm may be suggestive of superimposed atelectasis.     Assessment/Plan      41 y/o female presenting to MICU for worsening hypoxia diagnosed with COVID PNA. PMHx of obesity, OSA (noncompliant w/ cpap), FVL, prior DVT, salivary gland CA (s/p RUL lobectomy). Admitted to MICU for worsening hypoxia on HFNC, > 50% fio2. Admission evaluation with essentially unremarkable CBC and CMP, BNP negative. Vitals with normotensive, sinus tachycardia, afebrile. Blood Cx ngtd thus far. Has been on zosyn/azithro on the medical floor.   Admission Diagnosis:  Acute hypoxic Resp failure due to COVID PNA   NEURO:  Alert, oriented, no acute concerns   RESP:  ACUTE HYPOXIC RESP FAILURE  - initially on HFNC, worsening hypoxia  - start BIPAP - 10/13  - due to COVID PNA  - CT CHEST PE - at OSH - reportedly negative for PE  - - will try to obtain images for review  - US venous BUE/BLE - pending to definitively rule out VTE  - TTE - 10/13 - pending to evaluate pulm htn, shunt, etc  COVID PNA  - CXR - bilateral opacities consistent w/covid  - Cont remdesivir - 10/13 - 10/17  - Cont dexamethasone - 10/13 - 10/22 (10 days)  - Start baricitinib - 10/13 - 10/27 (14 days)  CAP  - empirically treating CAP, started on floor  - Cont zosyn/azithro (10/12 - present)  - - cont for now, though wbc wnl, afebrile  - - CXR without focal consolidation  - May be able to deescalate early after cx (-) after 48-72 hrs  h/o ASTHMA  - Albuterol q4h scheduled, q1h prn  - bronchodilator protocol  h/o RUL LOBECTOMY  - no acute concerns  h/o OSA  - no acute concerns   CV:  SINUS TACHYCARDIA  - due to sirs/inflammation, hypoxia  - monitor   GI:  No acute concerns  - regular diet   ENDO:  HYPERGLYCEMIA  - no DM2 in problem list  - will likely worsen with dexamethasone  - a1c pending  - start SSI insulin   ID:  COVID PNA  - see plan above  - Positive on 10/12; Sx 10/6  CAP  - empirically treating CAP, started on floor  - see plan above  - Cont zosyn/azithro (10/12 - present) for now  Antibiotics:  - Zosyn - 10/12 - present  - Azithro - 10/12 - present  Cultures:  - Blood Cx - 10/12 - pending x2  - Respiratory Cx - 10/12 - pending   DIET: diabetic diet  DISPO: MICU  CODE: Full  Prophy: enoxaparin   To be seen and staffed with AM attending   Problem List/Past Medical History   Ongoing  BMI 38.0-38.9,adult  Obesity  Historical  No qualifying data  Procedure/Surgical History  ?Bilateral PE Tubes ?Breast reduction ?C-sections ?Carpal tunnel surgery ?Upper right lung removed  Medications   Inpatient  albuterol HFA, 2 Puff, Inhalation, q1h, PRN  albuterol HFA, 4 Puff, Inhalation, q4h  azithromycin, 250 mg= 1 Tablet(s), Oral, Daily  baricitinib, 4 mg= 2 Tablet(s), Oral, Daily  dexAMETHAsone, 6 mg= 1.5 Tablet(s), Oral, Daily  enoxaparin, 40 mg= 0.4 mL, Subcutaneous, At Bedtime  hydrOXYzine hydrochloride 50 mg oral tablet, 25 mg= 0.5 Tablet(s), Oral, qid, PRN  influenza virus Vaccine PF 0.5 mL Syr Inj >= 6 months, 0.5 mL, IM, Unscheduled  melatonin 3 mg oral tablet, 6 mg= 2 Tablet(s), Oral, At Bedtime, PRN  Ocean, 1 Spray, IntraNasal, As Indicated, PRN  piperacillin-tazobactam, 3.375 g= 50 mL, IVPB, q8h-interval  remdesivir 100 mg intravenous injection  VANCOMYCIN IV - PHARMACY TO DOSE, 1 Each, Message, As Indicated, PRN  Home  albuterol  aspirin 81 mg oral delayed release tablet, 81 mg= 1 Tablet(s), Oral, Daily  cholecalciferol 2000 intl units oral capsule, 2000 IntUnits= 1 capsule(s), Oral, Daily  Cymbalta, Oral  diltiazem  Flonase 50 mcg/inh nasal spray, 1 Spray, IntraNasal, bid  hydrOXYzine  Mirena, IntraUterine, Once  Singulair, Oral, Daily  Symbicort, Inhalation, bid  Allergies   tobramycin ophthalmic (Eye swelling)  Social History   Smoking Status  Never smoker   Alcohol   Current, Liquor, 1-2 times per week   Employment/School   Work/School description: Mother of 2 children.   Home/Environment   Lives with Spouse. Living situation: Home/Independent.   Substance Abuse - Denies Substance Abuse   Tobacco - Denies Tobacco Use  Family History   Bleeding disorder: Brother.  Cancer: Mother.  Diabetes mellitus: Mother.  Hearing loss: Mother and Brother.  Heart disease: Mother and Father.  Hypertension: Mother and Father.  Immunizations        Vaccine  Date  Status        SARS-CoV-2 (COVID-19) mRNA-1273 vaccine 03/04/2021 Given         SARS-CoV-2 (COVID-19) mRNA-1273 vaccine 02/05/2021 Given         Addendum by MD,  on October 13, 2021 11:22:39 (Verified)    Patient seen and examined this morning.  Rapidly worsening respiratory status.   -Plan for intubation.  -Discontinued vancomycin and Zosyn.  -Started ceftriaxone.  -Discontinued baricitinib.  -We will give Tocilizumab.  -Continue remdesivir and dexamethasone.   Patient seen and staffed with Dr..   Addendum by MD, on October 14, 2021 05:31:17 (Verified)    On the above mentioned date as mentioned in the document header, the patient was seen and examined at the bedside. The key/critical portions of the medicine service were independently performed by me and the management was discussed in detail with the author of this document. Total critical care time spent on patient care excluding procedure  but including clinical case history, laboratory findings, microbiology data, medications, essential ICU flow sheets,ventilator data and imaging studies was > 74 minutes. I agree with the above documented assessment and plan except as follows:  Diagnosis: Acute hypoxic respiratory failure due to COVID-19 pneumonia s/p intubation 10/13/2021 Acute breakthrough COVID-19 pneumonia (moderna vaccination) Acute ARDS due to COVID-19 pneumonia  acute nonocclusive left popliteal vein deep vein thrombosis   PMH: Obesity, OSA noncompliant with CPAP, history of DVT in the past, salivary gland cancer status post right upper lobe lobectomy, baseline oxygen saturation between 85 to 90%   Labs: CBCD: WBC is 8.95, hemoglobin 13, hematocrit 40, platelet count 209 INR is 1 CMP: Sodium is 138, potassium is 4, chloride 101, bicarb 25, BUN is 12, creatinine 0.46, calcium is 8.9, magnesium is 1.8, albumin is 3.4, total protein 6.9, total bilirubin 0.34, alk phos 60, AST 57, ALT 69, Pro-Cal 0.09, ferritin is 196, CRP 16.21 UA negative for UTI ABG pH of 7.3, PCO2 48.8, PO2 of 76.4, bicarb 20.7, saturation 94.6, on 50% high flow nasal cannula Respiratory pathogen panel negative,    Imaging: CT chest PE negative, positive for COVID-19 pneumonia, bilateral upper extremity venous duplex negative for DVT Bilateral lower extremity venous duplex positive for acute nonocclusive left popliteal vein DVT   Management plan: COVID-19 pneumonia: Dexamethasone 10/12?10/21, remdesivir 10/12?10/17, Tocilizumab 10/13, ceftriaxone 10/13?10/17, azithromycin 10/13?10/15 Patient tachypneic on BiPAP 100% FiO2, patient intubated on 10/13/2021, placed on mechanical ventilator support on volume control ABG post intubation revealed PF ratio greater than 180, will hold off proning, s/p right IJ central line placement and right radial A-line placement Continue standard of care with steroids remdesivir Tocilizumab, will complete 5 days of ceftriaxone and 3 days of azithromycin, baricitinib stopped Continue bronchodilators on as needed basis, continue sedation with propofol analgesia with fentanyl Continue heparin drip for acute nonocclusive left popliteal vein DVT, continue GI prophylaxis Treatment plan discussed with patient prior to intubation, and with her husband Patient expressed her wish to be full code and wanted everything to be done to keep her alive