Discharge Provider:  Primary Care Provider: MD Admission Date: 4/19/2023 Discharge Date: May 3, 2023  PRESENTING PROBLEM: Hypoxia [R09.02] Pneumonia of both lungs due to infectious organism, unspecified part of lung [J18.9] Pneumonia due to COVID-19 virus [U07.1, J12.82] Acute hypoxemic respiratory failure [J96.01]   HOSPITAL COURSE: Patient is a 72 y.o. female with a past medical history of stage 3 chronic kidney disease and multiple sclerosis on chronic immunosuppression, among other co-morbid conditions who presented to the ED on 04/19/2023 with complaints of worsening generalized fatigue, cough and shortness of breath.    In the ER, she was afebrile and hemodynamically stable but with O2 sat 83% on room air. Viral swab was positive for COVID-19. Labwork otherwise stable aside from AKI. CXR showed bilateral infiltrates. She was placed on 6L NC, hydrated with 1L NS,  started on dexamethasone IV and admitted to Internal Medicine for further evaluation and treatment.   For treatment of acute hypoxic failure 2/2 COVID-19 pneumonia, dexamethasone was continued.  Remdesivir was deferred given the duration of her symptoms (approximately 20 days) prior to presentation.  With concern for superimposed bacterial pneumonia, she was treated with ceftriaxone/azithromycin IV. After 36-48 hours of admission, pt still had significant oxygen needs/symptoms and renal function had normalized so CTA thorax was obtained which showed bilateral emboli, both segmental a nonsegmental, though no right heart strain identified.  She was started on heparin drip. Pulmonology and IR were consulted for recommendations.   A 2D echocardiogram was obtained which suggested the presence of right heart strain.  Given the location of the thrombus, IR did not feel it was amenable for intervention.   On the morning of 04/24/2023 the patient acutely decompensated, with an acute hypoxia and tachypnea requiring NRB, then transitioned to HFNC. The patient was transferred to the ICU for close monitoring. Repeat CTA thorax showed no changes in PE, but persistent bilateral airspace consolidation and ground glass opacities. Duplex US negative for DVT. On the evening of 04/24/2023 she developed hypotension requiring low-dose norepinephrine but responded to fluid bolus. Pressors weaned off and pt transferred out of ICU on 04/26/3023. Patient has been weaned to 6 L nasal cannula oxygen at that time.   Remainder of hospitalization: Heparin was transitioned to oral eliquis. Completed 5 day course of IV abx. IV solumedrol was weaned to PO prednisone with planned taper to end on 5/14. Oxygen weaned to 1L NC. Patient symptomatically improved. She did notably have new onset DM 2 based on A1c of 7.7.  This was exacerbated by steroid induced hyperglycemia requiring basal bolus insulin initially while inpatient.  Once steroids were tapered down her insulin requirements decreased and she began to have more frequent lows.  Lantus was held at discharge.  Corrective insulin will continue at rehab and then patient should follow-up with PCP to discuss long-term management.   PTOT evaluation recommended inpatient rehab placement.. PMR consulted but recommended SAR.  Patient in agreement discharge plan and discharged in stable condition.