ED to Hosp-Admission  Discharged  9/13/2021 - 9/18/2021 (5 days)         Hospital Problems       * (Principal) COVID-19 Yes         Rheumatoid arthritis  Yes        RHEUMATOID ARTHRITIS;             Current use of long term anticoagulation Not Applicable         Supratherapeutic INR Yes         Acute hypoxemic respiratory failure Yes         Encephalopathy Yes         Poor prognosis Yes         Immunosuppressed status Yes  Presenting Problem/History of Present Illness/Reason for Admission Acute hypoxemic respiratory failure     Hospital Course 1.  Acute hypoxic respiratory failure secondary to COVID-19 pneumonia: Patient has been continued on remdesivir IV, Decadron 6 mg IV, infectious disease consultation appreciated patient is not a candidate for baricitinib as she has immunosuppression. 2.  Supratherapeutic INR: Patient got a dose of vitamin K  3.  Known rheumatoid arthritis on multiple immunosuppressive medications including prednisone methotrexate and rinvoq , hold on medications until she recovers from COVID-19 pneumonia.  4. Hypothermia likely related to severe infection with COVID: resolved    Because of the comorbidities, patient was extremely sick and was requiring very high oxygen she decided to change her CODE STATUS to comfort care, patient will be changed to hospice.   Operative Procedures Performed   Treatments: treated  for Covid, changed to comfort care Procedures: none Consults: none Pertinent Test Results:none Physical Exam at Discharge Heart Rate: (!) 104 Resp: (!) 24 BP: 119/84 Temperature: 36.6 °C (97.8 °F) Weight: 71.9 kg (158 lb 8.2 oz) General: Patient seems very sick, seems anxious HEENT: Atraumatic normocephalic Neck supple CVs: S1-S2 regular rate and rhythm Respiratory: Patient has bilateral coarse breath sounds, requiring supplemental oxygen with  nasal cannula Abdomen: Soft nontender bowel sounds present Neurologically: seems restless Patient has right BKA   Discharge Instructions Condition at Discharge Discharge Condition: very sick   Chief Complaint Patient presents with ? Shortness of Breath     1. Acute hypoxemic respiratory failure 2. COVID-19 3. Current use of long-term anticoagulation 4. Supratherapeutic INR 5. Poor prognosis 6. Encephalopathy   Plan:     Pulse oximetry continuously - high flow nasal cannula. Consult pulmonology.    Decadron 6mg IV daily   Remdesevir IV full course   guidelines advise AGAINST routine plasma use in hospitalized patients. I do not believe benefits > risks.    Spoke to ED physician personally   Given vitamin K to reverse INR > 9.8   Critical care time spent 60 minutes     o Nutrition: heart healthy if passes dysphagia screen o VTE prophylaxis: heparin o Full Code           History of Present Illness   a 69 y.o. female.       I personally interviewed patient, reviewed chart, and reviewed emergency room resident history and agree with it in its following entirety unless otherwise noted below.  " a 69 y.o. female w h/o DVT on coumadin, vaccinated against covid. presenting to the ED with weakness and fatigue for the past 2 weeks.  Patient is not able to provide much history.  Per her sister she has been ill for the past 2 weeks symptoms including weakness, fatigue, shortness of breath.  She is normally alert and oriented x3, no history of dementia.  She was seen in urgent care and prescribed antibiotics and steroids but she did not receive a Covid test.  She continued to worsen on the next couple days and her neighbors who checked on her, and she was not very responsive so they called EMS.  Per EMS patient was satting approximately 50% on room air and she was put on nonrebreather at 15 L and had improvement in saturation."   Patient is on high flow nasal cannula saturating in the upper 90s.  She has a very poor historian.   Not coughing just short of breath.   No edema   No rashes       Principal problem Acute hypoxic respiratory failure Covid pneumonia Rheumatoid arthritis-immunocompromised state     Patient was admitted to Hospital on 9/13 with Covid pneumonia and acute hypoxic respiratory failure.  She was requiring high flow nasal cannula at the time of admission.  She was started on Decadron and IV remdesivir. Due to the requirement of high flow nasal cannula pulmonology was consulted and also infectious disease was also consulted. Per infectious disease immunomodulators are contraindicated in this immunosuppressed patient.   Due to patient worsening respiratory state patient opted for comfort care and hospice.   Patient was changed to comfort care and was consulted on 9/17.   Patient is continued on comfort care medications with the help of the hospice   Patient died on 9/21 at 2320