Hospitalized 12.2.21 (currently  admitted in the ICU);  COVID-19 positive (12.1.21); fully vaccinated PLUS booster CHIEF COMPLAINT: Acute hypoxic respiratory failure HISTORY OF PRESENT ILLNESS:  a 67 y.o. male with h/o CLL, DM, HLD and tobacco use, transferring directly from ER, where he presented on 12/1 with c/o 1-week h/o fatigue, subjective fever, dyspnea, cough, chest tightness and loose stools.  Symptoms have gradually worsened over this interval and are primarily exacerbated by exertion. Symptoms worsened more significantly over the preceding 2 days, prompting presentation to a walk-in clinic, where he was redirected to the ER.  He has been vaccinated against COVID-19, including a recent booster. He is a heavy smoker who at baseline smokes 1.5 ppd with a 75 pack-year smoking history.  He rarely drinks alcohol and denies use of recreational drugs.   In the ER, he was afebrile, normotensive, with normal HR, tachypnic and hypoxic to 86% on baseline RA.  Labs are notable for leukocytosis, normocytic anemia, elevated proBNP, hyponatremia, hypochloremia, hypoalbuminemia, and positive COVID screen.  EKG shows SR with PAC?s.  CTA thorax shows mild pulmonary opacities c/w COVID pneumonia, diffuse lymphadenopathy minimally increased in size compared to imaging in recent months, mild emphysema and no evidence of PE.  He was treated with Decadron and transfer was requested d/t lack of bed availability.   Acute hypoxic respiratory failure COVID-19 pneumonia - Admit as inpatient, anticipate >2 midnight hospital stay. - Symptom onset 11/24.  PCR+ on 12/1. - Hypoxic to 86% on baseline RA, now on 4L via NC. - CTA thorax with bilateral opacities c/w COVID-19 pneumonia. - Continue Decadron 6 mg daily x 10 days. - begin remdesivir x 5 days. - Start Lovenox 40 mg SQ daily. - Supportive care, symptom management, proning PRN, encourage IS. - Monitor CPO and wean supplemental O2 as able. ASSESSMENT / PLAN: * Acute respiratory failure with hypoxia  PROGRESS NOTE FROM ICU on 12.15.21 - Assessment & Plan - 2/2 COVID-19 Pneumonia, suspected superimposed bacterial pneumonia, Progressive respiratory requiring intubation 12/9 - low tidal volume ventilation with goal tidal volumes of 4-8cc/kg of ideal body weight - goal plateau pressure less than 30 and driving pressure less than 15, will adjust PEEP and tidal volume to reach these goals. Will allow for permissive hypercapnea as long as pH > 7.2 - wean oxygen to keep SpO2 90-96% - continue intermittent proning if P/F  < 150 after optimizing vent settings - continue paralytics with deep sedation, didn't do well with trial of stopping 12/13 - COVID-specific therapy below - CAP coverage initiated 12/5 with azithro/ceftriaxone given clinical worsening and immunosuppressive status, would plan on 5d course of ceftriaxone. De-escalate based on culture data, strep/legionella  - Lasix for goal negative fluid balance - with fungal elements on bronch and immunosuppress status, would cont micafungin until fungitel and aspergillus Ag come back negative. Appreciate ID assistance Shock  Assessment & Plan - Septic from pneumonia, also exacerbated by sedation - wean vasopressors for goal MAP>65 Pneumonia due to COVID-19 virus Assessment & Plan - Symptom onset 11/24.  PCR+ on 12/1.   - CTA thorax with bilateral opacities c/w COVID-19 pneumonia. - Cont remdesivir x 5 days completed 12/6 - Dexamethasone 6mg qDaily started 12/1, escalated to IV Solumedrol 40mg BID 12/5, decrease solumedrol to 20mg IV BID 12/13 Atrial fibrillation with RVR - NEW DIAGNOSIS Assessment & Plan - CHADSVASC=3 - Continue heparin gtt given his elevated D-Dimer - Digoxin, added cardizem drip per cardiology recommendations but he required vasopressors, so will transition to amio gtt