Hospitalized (9.23.21 - present);  COVID-19 positive (9.23.21);  fully vaccinated  CHIEF COMPLAINT: Acute hypoxemic respiratory failure HISTORY OF PRESENT ILLNESS: Patient is a 54 y.o. female with past medical history significant for chronic obstructive pulmonary disease, chronic pancreatitis secondary to pancreatic divisum on opiate medications, opiate dependence who presents to the hospital with complaints of progressively worsening symptoms of fevers, shortness of breath over the last 2-5 days.  Majority of history obtained via chart review as patient was difficult to hold a conversation with and family was unreachable.  Patient reports that she has shortness of breath at baseline however noted conversational dyspnea and subsequently came to the emergency department.  Per discussion with emergency department nurse, patient was initially somnolent lethargic however subsequently became more agitated. Patient reports feeling thirsty, short of breath.   Review of systems significantly limited secondary to patient's inability to carry a conversation.   In the emergency department, patient was in initially tachycardic, hypotensive, tachypneic and initially required non-rebreather mask following which she was escalated to high-flow nasal cannula at 50 L at 100% FiO2 with 0.04 of norepinephrine for vasopressor support.  Initial laboratory results were notable for VBG demonstrating 7.21/74, potassium 3.1, magnesium 1.1, lactic acid 2.1, troponin 25 with repeat 21, creatinine 1.15, urine drug screen notable for opiates, white blood cell count 30 with left shift.  Patient was administered 1.5 L of normal saline, piperacillin-tazobactam, dexamethasone 6 mg, azithromycin 500 mg.  ASSESSMENT / PLAN: Patient is a 54-year-old woman with past medical history significant for chronic pancreatitis secondary to pancreatic divisum, opioid dependence, chronic obstructive pulmonary disease who was admitted for acute hypoxic, hypercapnic respiratory failure and septic shock likely secondary to COVID-19 pneumonia Acute hypoxic, hypercapnic respiratory failure secondary to COVID-19 pneumonia Septic shock secondary to COVID-19 pneumonia Lactic acidosis Concern for RLL parapneumonic effusion vs empyema Vaccinated 6/2021. Can not rule out superimposed bacterial infection - continue HFNC, evaluate with serial VBG q4h for need for intubation - trend lactic every 4 hours - pneumonia workup:  Procalcitonin, strep pneumo urinary antigen, Legionella urinary antigen, respiratory film array, MRSA screen PCR, sputum culture - follow-up blood culture - broad-spectrum antibiotics:  Vancomycin, piperacillin-tazobactam, azithromycin - EKG to evaluate QTC - consider chest tube placement Progress Note 9.30.21:  Acute on Chronic Hypoxic, Hypercapnic Respiratory Failure Septic Shock 2/2 Strep pneumoniae bacteremia COVID 19 - suspected incidental finding Right lung empyema Severe COPD on 3L baseline Vaccinated 6/21. Intubated 9/24. Suspect COVID-19 infection is likely incidental and not contributing significantly to the patient's current respiratory status given formation chest imaging largely consistent with bacterial pneumonia. o MAP goal >65 o Ceftriaxone day 6/14 o Prednisone taper o Duoneb q6h, albuterol nebs, hypertonic saline neb, Dulera inhaler o Continue Seroquel 50 mg 2 times a day o Continue oxycodone 10 mg every 6 hours o Passed SBT, Plan for extubation today