COVID+ 11/27/2022.  Vaccination Status - pfizer x3 BRIEF OVERVIEW: Discharge Provider: DO Primary Care Provider: MD Admission Date: 11/27/2022 Discharge Date: Dec 2, 2022   Active Hospital Problems   Diagnosis Date Noted POA ? Chronic obstructive pulmonary disease with (acute) exacerbation 07/18/2022 Yes ? Obstructive sleep apnea 12/22/2021 Unknown ? Pneumonia of both lower lobes 12/01/2022 Unknown ? COVID-19 12/01/2022 Unknown ? Hypokalemia 11/28/2022 Yes ? Acute hypoxemic respiratory failure 11/27/2022 Yes ? Morbid obesity with BMI of 45.0-49.9, adult  06/28/2022 Yes ? Type 2 diabetes mellitus with diabetic polyneuropathy, without long-term current use of insulin  Yes ? Acute on chronic combined systolic and diastolic congestive heart failure  Active Issues Requiring Follow-up:  Chronic obstructive pulmonary disease with (acute) exacerbation  Assessment & Plan CXR shows interstitial edema (atypical) Treated for COPD exacerbation secondary to pneumonia (COVID +, SC mixed oral flora) Begin Solumedrol wean MDI's:  Spiriva 2 puffs daily, Symbicort 2 puffs BID, Albuterol MDI prn IS, Acapella, SC 12/01/2022-improving with Solu-Medrol and albuterol MDI. 12/2 - see above plan COVID-19 Assessment & Plan Patient completed 5 days of Remdesivir today w/ stable renal and hepatic function  Acute on chronic combined systolic and diastolic congestive heart failure  Assessment & Plan Continue Lasix IV BID to be continued Diastolic dysfunction didn't show on last echo, but will update echo to see if diastolic dysfunction is present.   Monitor I/O's, daily weights Continue fluid and salt restriction Repeat labs and CXR in am Reviewed recent echo Continue Aldactone, Inderal, Lisinopril 12/01/2022- good diuresis of 2460 mL the last 24 hours.  Continue Lasix 40 mg IV 2 times a day * Acute hypoxemic respiratory failure  Assessment & Plan Patient normally uses CPAP at home, but is unable to use this d/t COVID 19 infection.   Worse She typically uses 2-3L NC at home and has worsened since admission.  She is now on HFNC.   She is a lot more bronchospastic CXR shows more interstitial edema  SC + for mixed oral flora.   Remdesivir completed 12/2 .  Plan: Monitor CMP for a few more days s/p remdesivir  Changed Decadron to Solumedrol at 60 mg IV q 6 hours and will wean today if improved Continue Mucinex and Tessalon Continue MDI's.   IV Lasix Limited echo to re-eval EF Monitor D dimer, CBC, CRP IS, Acapella, SC Per SC results, will DC Doxy and Rocephin and give Augmentin.  ? ST eval.   Repeat CXR in am and consider CTA thorax if D dimer increases.    12/01/2022 improved from requiring high-flow nasal cannula oxygen at 50% at 40 liters/minute to 6 liters/minute nasal cannula.  Chest x-ray appearance shows improving infiltrates which I suspect is due to decreasing pulmonary edema with diuresis more than improvement in underlying infectious etiology.  Home O2 is at 2-3 L.  Continue to treat CHF, chronic obstructive pulmonary disease exacerbation, bacterial pneumonia, and COVID-19  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Acute hypoxemic respiratory failure due to COVID-19 [U07.1, J96.01]  HOSPITAL COURSE: Patient is a pleasant 66 y/o morbidly obese female with a complex medical history who was admitted to our hospital for acute respiratory failure secondary to COVID 19.  She required BIPAP for long periods as well as HFNC.  She seemed to turn around when she was diuresed more aggressively and when her decadron was converted to Solmedrol.  She received the full dose of Remdesivir.    She titrated fro HFNC as high as 50% FiO2 at 40L/min down to current level of 5 L via NC.  She is normally on 2-3 L at home and BIPAP at night.  The patient unfortunately was insistent on going home despite being on Solumedrol 60 mg IV q 6hours and Bumex 2 mg IV BID.  I asked her to give me a few days to convert her to oral medication to make sure that she could tolerate the conversion to PO steroids and diuretics, but she declined.    The patient is signing herself out AMA.  I am concerned for her safety from a CHF and bronchitis standpoint, so I made some recommendations and faxed some prescriptions to her pharmacy in order to help her transition to home.   She will increase her Bumex to 2 mg PO BID x 5 days and then resume her 1 mg PO BID dosage unless otherwise directed by her PCP.  She will have labs drawn in 4 days, but continue her potassium supplement that she takes at home.  She will also be given a prescription for magnesium 400mg PO TID.    For her COVID 19 pneumonitis, she will continue a steroid taper after discharge.  She completed her course of Remdesivir.  She will continue Duoneb and Albuterol as she takes at home and was given a prescription for Symbicort.  She was given an rx for Mucinex also.  She will go home on 5L NC.