Hospitalized (from ED 10.22.21 - present; still admitted);  COVID-19 positive (10.22.21);  fully vaccinated HISTORY OF PRESENT ILLNESS: Patient is a 70 y.o. male who presents today as a transfer from emergency department due to a 2 day history of shortness of breath.  Patient states on Thursday she was doing yd work and tripped over a step back and so, since that time he he has been fatigued and very short of breath which prompted evaluation in emergency department.  Patient states she is not taking voriconazole since Tuesday as he has run out of his prescription.  Patient states he has a cough that is productive of yellow sputum that is unchanged.  No unexpected weight loss, fevers, chills, wheezing.  He takes albuterol nebulizers as needed, and has recently noticed that he rated 2 per day instead of 1, this change started in July.  Patient also has a history of essential thrombocytosis evaluated by bone marrow biopsy in 2017 with a confirmed JAX 2 mutation and has found hydroxyurea since.  No new environmental exposures, no current PJP prophylaxis. Patient has an extensive pulmonary history consisting of asthma, chronic bronchiectasis, non resolving right lower lobe opacity.  He is a former smoker and quit 1999. He was a warehouse manager for a foundry with exposure to silicone in Elroy dust, patient worked there for approximately 60 years.  No pets in the house.  He was originally worked up for fever and hemoptysis in September of 2019. He was found to have a right lower lobe possible aspergilloma versus other.  At this time he was started on voriconazole and prednisone.  In June of 2020 he underwent a bronchoscopy which grew Nocardia species and was subsequently placed on Bactrim.  At that time tuberculosis was ruled out.  Monthly LFT, IgE, complete blood count labs have been drawn due to voriconazole use.  A CT-guided right lung biopsy was performed in September 2021 which showed no evidence of malignancy or granulomatous inflammation, with patchy chronic inflammation with lymphoid aggregates and nonspecific scarring along with polyclonal plasma cells.  These changes are consistent with chronic inflammation but cannot rule out lymphoproliferative disorder.  At this time he was referred to University pulmonary for a 2nd opinion and his appointment is scheduled for next month. In the emergency room he was found to be hypoxic requiring 4 L nasal cannula.  A chest x-ray showed a chronic right hilar mass unchanged upon review of prior imaging.  Metabolic panel unremarkable, complete blood count with leukocytosis, COVID negative, urinalysis unremarkable, procalcitonin 0.07.  ABG was ordered which showed hypoxia with PO2 of 61.3.  Due to this hypoxia a Venturi mask was placed and patient was transferred to Hospital for further evaluation.  During his emergency department visit he received DuoNeb and methylprednisolone 125mg. Patient is a 70 y.o. male with a past medical history of aspergillosis currently on voriconazole presents with increasing dyspnea and oxygen demands, ruling out worsening disease process vs infection vs medication side effect AHRF Bronchiectasis Allergic Bronchopulmonary Aspergillosis Patient presented hypoxic requiring Venturi mask, patient does not use oxygen at baseline Currently being followed by outpatient pulmonology and the skin with plans for 2nd opinion at the University.  Pulmonary risk factors include history of tobacco use, silicosis exposure at work, bronchiectasis Recent CT-guided biopsy of right lung lesion showed chronic inflammation, no granulomas or malignancy Increased oxygen demands could be secondary to Pneumocystis infection as patient is not on prophylactic Bactrim.  Less likely progression of aspergillosis as patient' has only missed medication for 4 days.  Unlikely bacterial infection given normal procalcitonin lack of constitutional symptoms.  Cannot rule out medication side effect from hydroxyurea Plan - Consult to Pulmonology - Will begin Bactrim for PJP prophylaxis - Methylprednisolone 60mg three times daily - Restart home voriconazole - Continuous pulse ox, - CTA to rule out PE, though patient has contrast allergy, will need to pretreat - Chest PT - Will obtain IgE to compare to recent outpatient labs  - Duonebs as needed for shortness of breath, Dulera BID Patient presented with SOB,cardiac biomarkers elevated, found to have saddle pulmonary embolism with a large clot burden and evidence of right heart strain. US LE notable for extensive occlusive DVT from the femoral vein into the calf veins. s/p IR thrombectomy 10/23/21. Patient also found to be COVID positive, believes symptoms started 10/21.  Sputum culture from 10/23 grew staph aureus. Chest X ray stable.