Hospitalized 10/5/2021; COVID-19 positive 10/2/2021; fully vaccinated  Admission note 10/5/2021 HISTORY OF PRESENT ILLNESS: Patient is a 80 y.o. male with a past medical history of non ischemic cardiomyopathy status post ICD, MR, CKD 4, coronary artery disease, hypertension, GERD, type 2 diabetes complicated by neuropathy, TIA who presents with COVID-19 pneumonia with acute hypoxic respiratory failure.  Patient is vaccinated and was exposed to COVID-19 by his son and started having symptoms on 09/29 which included cough, sore throat, myalgias, headache.  He was seen in the emergency department on 10/02 where he was tested positive for COVID-19 was given IV steroids.  He was discharged home as he was satting in the 90s on room air while ambulating.  He presented back to the emergency department with worsening shortness of breath.   In the emergency department, he was noted to be hypertensive and hypoxic to the 70s on room air requiring up to 4 L oxygen by nasal cannula.  Labs remarkable for creatinine 1.9, BNP 4000, troponin 28 with a peak of 193 and repeat 176, CRP 30, WBC 11.75, D-dimer 1160. A chest x-ray revealed moderate pulmonary edema that could be superimposed over COVID-19 pneumonia.  CT angiogram thorax revealed no PE, revealed bilateral bronchopneumonia and very small bilateral pleural effusions.  He was treated with Bumex with good urinary output.  He was also started on dexamethasone, and was not started on remdesivir due to poor renal function.  Due to patient's rising troponin, patient was discussed with Cardiology in the emergency department who recommended heparinizing the patient and possible echo due to concern for NSTEMI.  Patient's transfer was delayed due to bid and transport availability.  He was admitted to Hospital for further evaluation and management. Prior physician notes, labs, imaging reviewed. Note from 10/6/2021: Assessment/Plan    ASSESSMENT / PLAN: Principal Problem:   COVID-19     # COVID-19 -in the setting of known vaccination -symptom onset approximately 9/29, tested positive 10/2 -steroid started 10/2, now is day 5 of steroids -remdesivir started 10/6 -continue with supplemental oxygen, goal oxygen saturation greater than 92% -continue enhanced isolation precautions for now   # Acute hypoxic respiratory failure -in the setting of COVID-19  -currently on 6 L saturating 96% -continue with management as stated above for COVID-19 -inflammatory markers slightly elevated today, CT PE study 10/5 negative for PE -monitor volume status closely, currently on bumetanide 1 mg daily   # Elevated troponin I with concern for NSTEMI type 2 -cardiology involved, in the setting of known coronary artery disease with ischemic cardiomyopathy -currently chest pain free -EKG showed no acute ST or T-wave changes -patient's echo shows approximately same ejection fraction but anterior wall appears hypokinetic -uncertain what to make of anterior wall hypokinesis -cardiology believes patient's overall presentation more likely representative of COVID-19 infection, less likely ACS -recommendation to continue heparin for 48 hours, then DC last indication for therapeutic anticoagulation presents itself -continue aspirin, atorvastatin, carvedilol