Hospitalized (9.25.21 - present; now in ICU intubated);  COVID-19 positive (9.16.21);  Fully Vaccinated  HPI from admission: HISTORY OF PRESENT ILLNESS: Patient is a 66 y.o. male who presents today with SOB.  He has a known history of coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation on Xarelto.  He is fully vaccinated against COVID-19.  He presents the emergency department complaining of shortness breath that started 12 days ago.   He eventually got tested + for COVID-19 09/16/2021.  He has been monitoring his oxygen level at home when it was noted that he has been dropping below 80s.  He then proceeded to be evaluated emergency department.  He has been having generalized weakness and fatigue with mild cough. He denies chest pain nor hemoptysis.  He has had intermittent fevers.  He reports diarrhea, no abdominal pain. He states he initially lost his sense of taste and smell but slowly regaining it back.  On admission his blood pressure is 153/79 heart rate 89 respiratory rate 25 94%  NRB  Chest x-ray showing bibasilar airspace opacities likely due to pneumonia.  ASSESSMENT / PLAN: Acute respiratory failure COVID 19 pneumonia Received Pfizer COVID 19 vaccine 5/2021 Symptom onset 9/14/21 Positive test 09/16/2021 Chest x-ray showing bilateral airspace opacities Decadron 6 mg daily  Out of the window for remdesivir Monitor CRP D-dimer Check procalcitonin Elevated procalcitonin at 0.27 Blood culture and sputum cultures Rocephin and azithromycin x5 days  Progress note from 10.6.21:  (intubated in ICU; declining status) ASSESSMENT / PLAN: 66 y.o. vaccinated patient with morbid obesity (BMI 34), aflutter on Xarelto, CAD (STEMI 12/4/2008 s/p D1 DES), HTN, hyperlipidemia, GERD presented with COVID-19 pneumonia on 9/25. AKI improving. Mild hepatitis. Symptom onset 9/14, positive test 9/16. Prior to this had newly identified well differentiated neuroendocrine tumors in his duodenum and was planning to undergo surgical resection 10/14/21. Otherwise does not appear to be immunosuppressed.  Transferred to ICU 10/1 with progressive hypoxia as cc2; supported w/ HHFNC and prn NRBM. Assessment and Plan Acute respiratory failure with hypoxia Assessment & Plan Due to COVID-19 Pneumonia   9/26: On 100% HFNC and NRB 10/2:  Intubated FIO2 (%): 60 % Type of Mechanical Vent: Avea Mechanical Rate: 34 breaths/min Set/Target Tidal Volume: 510 PEEP (cm H2O): 14 cm H2O   Plan: - Lung protective ventilation - adjust Vt/Peep for pplat < 30 and driving pressure < 15 as able - daily assessment for prone position 16/8 for p/f < 150 (until p/f > 150 on Peep 10 or less and fio2 60% or less) Serial ABG - collect sputum culture - continue steroids   * Pneumonia due to COVID-19 virus Overview Vaccinated: Pfizer 4/5/21, 5/3/21 Symptom onset 9/14 Positive test 9/16 Admission 9/25 Intubated 10/2 Treatment: Remdesivir: out of window Tocilizumab: none due to shortage  Steroids: Dexamethasone 9/25 - 9/26 Methylprednisolone 60 mg iv q 12 9/26 -    Assessment & Plan Patient has confirmedSARS-CoV-2/COVID-19 infection Vaccinated Isolation: Severe respiratory isolation Risk stratification (High if 1 from each or >1 clinical criteria): History -  Age >/= 60 years old, History of cardiovascular disease, Diabetes (A1C >/= 7.6), BMI  >/= 30 Labs:  - Daily labs qAM: CMP, CBC with diff, - Every other day: CRP, ferritin, Fibrinogen, LDH, D-dimer, triglycerides. Therapy: - Dexamethasone 6mg daily transitioned to methylprednisolone - Unable to provide remdesivir or tocilizumab   Respiratory failure and hemodynamics: Lung protective ventilation with 4-6 ml/kg and appropriate PEEP escalation.  Initiate neuromuscular blockade and proning as appropriate.   Concern for arrhythmia/hemodynamic worsening.  Consider EKG and bedside cardiac US, evaluate for need for TTE.   Pneumomediastinum  Assessment & Plan - extensive, related to COVID-19, ARDS Plan: - okay to continue to monitor as there is no evidence of pneumothorax - monitor for changes in peak and plateau airway pressures.   Shock  Assessment & Plan - unclear etiology: Cardiogenic versus hemorrhagic versus adrenal insufficiency.   - echocardiogram with no valvular dysfunction and normal LVEF. - troponins unremarkable Plan: - resolved at this time - continue antibiotics - stress dose steroids not continued