Discharge Provider: DO Primary Care Provider: PA Admission Date: 11/8/2022 Transfer Date (Hospital):  11/20/2022  PRESENTING PROBLEM: Vomiting and diarrhea [R11.10, R19.7] Acute dehydration [E86.0] Sepsis [A41.9] Acute hypoxemic respiratory failure [J96.01]   HOSPITAL COURSE: 51-year-old female with medical history of rheumatoid arthritis on multiple immuno modulator medications presented to the emergency department on November 8th for worsening dyspnea and hypoxia.  Patient was recently seen in hospital here for COVID pneumonia to which she was weaned off of nasal cannula back on to room air.  Patient was treated with remdesivir and Decadron with antibiotic coverage.  Patient was stable on discharge and discharged with finishing course of Decadron and Levaquin.  Patient returned to emergency department approximately 4 days after discharge with worsening dyspnea, cough, fatigue.  Patient was found to be hypoxic in dim placed on nasal cannula.  Chest x-ray did show drastic worsening of COVID pneumonia.  Patient was placed on steroids once more with antibiotic coverage.  Patient oxygen requirements quickly increased as patient was placed on high-flow.  Infectious Disease and Critical Care were consulted due to fast increase in oxygen requirement.  CTA was performed and did not demonstrate any pulmonary emboli at 1st, but did show possible organizing pneumonia as well as likely COVID pneumonia.  She patient was placed on vanc Zosyn, however MRSA swabs are negative and deescalated to just Zosyn.  Multiple fungal cultures were taken all negative.  Patient continued to wax and wane on high-flow oxygen not being able to be reduced to normal nasal cannula.  Given stagnation of patient repeat CT chest was ordered, which did demonstrate improvement in pneumonia however multiple pulmonary emboli were demonstrated without right heart strain.  Echo confirmed that there was no right heart strain.  Patient was placed on heparin drip.  The Zosyn was discontinued and Bactrim was initiated for PCP treatment.  Unfortunately patient oxygen requirements continue to increase more to almost maxed thing out high-flow.  Discussion was made with critical care team to transfer patient for possible thrombectomy, bronch, repeat echo with suspicion right heart strain. Multiple subsegmental pulmonary emboli without acute cor pulmonale, noted 11/18/2022 Assessment & Plan CT chest with contrast demonstrating multiple pulmonary emboli with no signs of right heart strain Echo shows preserved left and right ventricular function, no signs of heart strain Patient initiated on heparin drip Respiratory support as above via high-flow, requirements continued to increase however is not complaining of chest pain Dopplers did demonstrate nonocclusive DVT, will repeat on Monday to monitor resolution Transferred to hospital, will repeat echo and determine possible need for thrombectomy.  Discharge Provider: DO Primary Care Provider : PA  Admission Date/Transfer from Hospital: 11/20/2022 Discharge Date: 12/07/2022 COVID positive Date: 11/1/2022 & 11/11/2022 Admitting Diagnoses: Principal Problem:   Acute respiratory failure with hypoxemia  Active Problems:   Pneumonia due to COVID-19 virus   Transaminitis   Rheumatoid arthritis    Multiple subsegmental pulmonary emboli without acute cor pulmonale, noted 11/18/2022   Acute hypercapnic respiratory failure    Steroid-induced hyperglycemia   Prediabetes  PRESENTING PROBLEM: Acute respiratory failure with hypoxemia    HOSPITAL COURSE: Patient is a 51-year-old female with past medical history significant for rheumatoid arthritis on methotrexate and Rituxan and chronic steroids who transferred from ICU to different ICU    She was admitted from 11/1 to 11/4. She completed a course of remdesivir, Decadron, and antibiotic coverage.     However, patient returned on the 8th of November for worsening dyspnea, cough, and generalized fatigue/weakness. She was then admitted to ICU from 11/8 to 11/20 prior to transfer to different ICU on 11/20.     At the time of presentation to hospital on 11/8, chest x-ray did show worsening COVID pneumonia and was placed on antibiotics.  However, respiratory status continued to worsen and oxygen requirement quickly increased it where patient was placed on high-flow nasal cannula.  Patient was also seen and evaluated by Infectious Disease and Critical Care were consulted.  CTA performed and did not demonstrate any pulmonary emboli however it did show possible organizing pneumonia.  Patient was started on Zosyn and vancomycin which was later discontinued as MRSA swab was negative. Fungal workup has been negative.  Given continuous worsening of respiratory status, CT thorax with IV contrast was performed on 11/18 which was significant for improvement of pneumonia however did show multiple pulmonary emboli.  Bilateral lower extremity duplex was also obtained significant for acute nonocclusive thrombus within the right peroneal vein.  An echocardiogram was obtained on 11/18/2022 demonstrating LVEF 74% with no evidence of right heart strain.  The echo also demonstrated  LV mildly dilated with normal systolic function.  Although Zosyn was discontinued and Bactrim was initiated for PCP treatment, patient's oxygen requirement continue to increase.  Case was discussed with intensive care unit at Hospital and patient will be transferred for further workup including a possible thrombectomy with I.R.    She was admitted as cc1 to MICU. IR did not recommend thrombectomy. She was treated with iv heparin and iv lasix throughout admission. She received a full course of antibiotics at hospital with Cefepime and Vanco from 5 days from 11/8 to 11/13 and another 7 days of zosyn from 11/12 to 11/20.   ID was consulted and stopped bactrim for pjp empiric treatment. She had no covid antibiotics in spite of vaccination so she was given convalescent plasma on 11/23.    She transferrd out of micu on 11/21 but transferred back to micu for cc2 on 11/24 for high o2 requirements. She maintained on high dose steroid with slow improvement.    Bactrim resumed for pjp prophylaxis on 11/27. Potassium and renal function remained stable    She maintained euvolemia around 84 kg.    Steroids were slowly weaned along with hfnc requirements.    Patient was gradually weaned to oxygen requiring 2 L at rest and up to 10 L with activity.  Home oxygen was arranged.  Patient is to continue with a steroid taper as specified by pulmonary team.  Patient to follow-up with pulmonary team and have repeat CT thorax outpatient setting in 4-6 weeks