Admission Date: 12/19/2022 Discharge Date: 12/24/2022 COVID positive date: 12/20/2022   Admitting Diagnoses: Acute respiratory failure with hypoxia PRESENTING PROBLEM:  Hypoxia Warfarin anticoagulation Acute respiratory failure with hypoxia Acute on chronic congestive heart failure, unspecified heart failure type Pneumonia due to COVID-19 virus COVID-19   HOSPITAL COURSE: Per history of present illness "The patient is a 81 y.o. female with past medical history significant for nonischemic cardiomyopathy, stage 3 chronic kidney disease, acquired hypothyroidism, hyperlipidemia, DVT/PE on Coumadin, chronic combined systolic and diastolic heart failure, adrenal mass, hypertension, Crohn's disease, epilepsy, history of breast cancer, presented to the emergency department with chief complaint of difficulty breathing.  Patient is currently BiPAP with difficulty answering questions, also information is obtained from neighbor was at bedside, emergency physician, and staff nurse.  According to the neighbor, the patient took a home a COVID test 3 days ago that was positive.  Today, patient woke up and was having breathing difficulties.  Patient notified her neighbor.  The patient apparently also had a visiting nurse that came and evaluated patient who subsequently requested EMS to transport patient to the emergency department for difficulty breathing.  Patient was also complaining of some chest discomfort.   In the emergency department, patient became progressively dyspneic and was transitioned from high-flow nasal cannula to BiPAP.  With concern for pulmonary edema, patient received nitroglycerin paste.  Chest x-ray with evidence of pneumonia versus interstitial pulmonary edema.  BNP was elevated at 8827. EKG without acute ischemic changes.  Troponins 28 and 34 respectively.  Venous blood gas with evidence of normal pH with his pCO2 of 49.1.  Other labs showed evidence of hypokalemia with potassium of 3.3, chronic kidney disease stage 3, stable, elevated alkaline phosphatase of 153, elevated glucose of 205, elevated AST of 37. Patient with evidence of elevated inflammatory markers with CRP of 20 and sed rate of 21. Procalcitonin 0.06.  Thyroid studies within normal limits.  Viral PCR positive for COVID-19.  Urinalysis negative for infection.    Given patient's increased oxygen demands with need for BiPAP, patient was empirically started on treatment for community-acquired pneumonia and remdesivir for COVID-19 along with Decadron.  Patient was admitted to the intensive care unit for further management." Patient able to come off of BiPAP down to nasal cannula.  She underwent treatment for COVID 19 pneumonia and acute on chronic systolic heart failure.  TTE done 12/20 showed reduction of ejection fraction from 32 to 25%.  Also showed global left ventricular hypokinesia, LV dilation.  Patient had good response with IV Lasix, was able to wean down oxygen requirements.  Patient did develop hypokalemia, needed to be started on daily potassium supplements.  Patient was transitioned to oral Lasix 40 mg once daily.  Her supplemental oxygen was weaned off 12/23.  She did not display any other signs of superimposed bacterial infection.  She was given treatment for community-acquired pneumonia empirically with Rocephin and azithromycin.  Patient also received course of remdesivir.  She has had 4 days of both antibiotics and remdesivir, on 5th day her IV went bad and patient declined to have further IV placed.  Since she has had significant improvement, patient was not given antibiotics for the 5th day.  PT/OT evaluated, recommended discharge home with home health.  12/24 patient underwent home oxygen evaluation, found to have normal oxygen saturations without need for supplemental oxygen on both rest and activity.  Patient was instructed to continue using Lasix and potassium daily until she sees her cardiologist.  Patient advised to follow-up with PCP regarding her incidental adrenal gland lesion detected on CT abdomen in November 2022. She will be sent home with 5 days of dexamethasone. Patient being discharged home today in stable condition with family.