Hospitalized 10/4/2021; COVID-19 positive 10/04/2021; fully vaccinated  HISTORY OF PRESENT ILLNESS: HPI  Patient is an 84-year-old female with a past medical history of hypertension, interstitial lung disease, rheumatoid arthritis, pulmonary hypertension on 5 L at baseline who presents to the emergency department today via EMS for shortness of breath. Patient states she has had worsening shortness of breath over the last 3 days.  She states that she is normally on 5 L of oxygen at baseline is had increase up to 9 L. patient states she has had a productive cough.  She states she had a low-grade fever of 99.  Patient has no signs of peripheral edema.  Remainder of physical exam noncontributory. I ordered basic labs, troponin, EKG, COVID-19 PCR, BNP and chest x-ray. My working differential diagnosis included, but is not limited to congestive heart failure exacerbation, ACS, pneumonia, COVID-19 or worsening of her interstitial lung disease.  As patient is taking her Xarelto as directed, I have low suspicion for pulmonary embolism and do not feel advanced imaging or lab work is warranted to pursue that diagnosis. COVID-19 PCR was positive.  Chest x-ray shows acute airspace disease with superimposed chronic lung disease in the right lower chest.  With the patient's worsening respiratory status from her baseline and elevated BNP, patient is given a dose of IV Lasix.  Due to her COVID-19 positive status, I gave the patient a dose of Decadron.  Patient and her daughter were updated on lab and imaging results.  We discussed her diagnosis of COVID-19 with likely worsening CHF.  As patient has maxed out on her oxygen capabilities at home, we did discuss admission for this. CHIEF COMPLAINT   Pneumonia due to COVID-19 virus   ASSESSMENT AND PLAN Principal Problem:   Pneumonia due to COVID-19 virus COVID-19 pneumonia -pt is vaccinated but immunocompromised, onset of increased oxygen demands 10/1/21 -s/p moderna vaccine 2/3/21 and 3/20/21 -CXR showed acute airspace disease superimposed on chronic lung disease in the right lower chest -start decadron and remdesivir   acute exacerbation of chronic 5-8L O2 dependent interstitial lung disease, pulmonary hypertension -2/2 above, did not improve with prednisone 50mg qday 10/1 -follows up pt with pulmonologists as outpatient -pulmonology consult, await recommendations -continue home sildenafil and tyvaso -PRN albuterol -continuous pulse ox Note from 10/6/2021: ASSESSMENT/PLAN:   Acute on chronic hypoxic respiratory failure COVID-19 PNA Interstitial lung disease -Patient reports she's on 6 L oxygen at rest at baseline, goes up to 10 with exertion -currently on 6 L with rest but using NRB to ambulate.  -Pulm consulted              -continue dexamethasone              -started remdesivir              -started IV lasix, AM labs pending              -continue PJP prophylaxis              -hold cellcept Note from pulmonary on 10/6/2021: ASSESSMENT / PLAN: This is a 84 y.o. who has a past medical history significant for RA-ILD and PH on tyvaso and sildenafil, afib on DOAC admitted for hypoxic respiratory failure 2/2 covid-19.   Assessment and Plan #acute on chronic hypoxemic RF #COVID-19 On baseline 3L, currently requiring 6L and more with exertion. Feels better today. - please start to wean O2 to keep sats >90% - cont dexamethasone 6 mg daily  - remdesivir 200 mg loading dose then 100 mg daily - procalcitonin 0.04 so will hold off empiric abx - continue lasix to 40 mg IV daily, can transition back to home PO dose once O2 requirement is decreasing - less likely PE in the setting of DOAC though please low threshold to get CTA chest if she has increasing O2 requirement - daily CMP while on remdesivir