Hospitalized 09/30/2021; COVID-19 positive 09/30/2021; fully vaccinated  Patient is a 72-year-old female presents the chief complaint of fever, fatigue, shortness of breath.  Upon initial evaluation she is hypoxic to 86%.  Placed on 2 L nasal cannula with good response.  COVID-19 testing is positive.  She has an AKI evident on CMP.  Lactic acid slightly elevated 2.2.  She is given 2 L IV fluids for her AKI and lactic acidosis.  She does not have a history of decreased EF.  Chest x-ray is consistent with COVID-19 pneumonia.  She is given 6 mg IV Decadron.  I spoke with the hospitalist who agrees to admission and further management of this patient. Assessment/Plan  DIAGNOSIS at time of disposition: 1. Pneumonia due to COVID-19 virus  2. Hypoxia  3. Respiratory insufficiency  4. AKI (acute kidney injury)  5. Lactic acidosis  10/3/2021 note:  ASSESSMENT / PLAN: Pneumonia due to COVID-19 virus Assessment & Plan Continue remdesivir, inhaled steroid, inhaled beta stimulant, inhaled Spiriva, supplemental oxygen, empirical antibiotic coverage as well given the presence of elevated procalcitonin. She received dexamethasone on hospital day 1 when she was still in ER and then she became confused and agitated, she threatened to leave AMA on hospital day 2 at 7a.m., she was agitated.  She did calm down subsequently and I have found out that she does tolerate small amounts of inhaled steroids but not oral steroids.  Therefore I switched to the available in the hospital equivalent of  Trelegy she takes as an outpatient specifically Dulera and Spiriva  plus p.r.n. albuterol. Vitamin C, zinc are also being given. DVT prophylaxis Acute respiratory failure with hypoxia  Assessment & Plan Continue high-flow nasal cannula oxygen, she is saturating 93 up to 95% on 60 L, plus non-rebreather, FiO2 is 100%.  If she worsens then next step would be intubation 10/8/2021 note: Assessment/Plan: Pneumonia due to COVID-19 virus Assessment & Plan Will continue with present medical regimen.  Will give a dose of Lasix today 10/05/2021 will give dose of Lasix today.  Also talked her about the steroid issue.  She wants to try it again.  I thought I had given to her orally my diet have the same subjective feelings that she has been getting with the IV steroids 10/06/2021 her D-dimers markedly elevated at 11,000 thousand.  I have empirically started her on heparin drip.  Will send her down for a CT angiogram.  Will also schedule her for upper lower extremity Dopplers.  Clinically she says she feels better today than she did yesterday. 10/07/2021 initially she had an elevated procalcitonin question of an infiltrate.  Procalcitonin has normalized but there is consolidation at the mention on her CT scan.  I decided to continue broad-spectrum antibiotics for now.  In light of her declining respiratory status will move her to the intensive care unit 10/08/2021 she finished remdesivir, she is refusing the empirical antibiotic coverage.  Will check a procalcitonin in the morning.  She is on the inhaled steroid but she refused the intravenous Solu-Medrol. 10/08/2021 the patient stated to me and also she stated in no uncertain terms to the previous physician that she does not desire intubation in case that she deteriorates to that point.  I do intend to honor this and she is therefore a do not resuscitate.  However it should be noted that she is now maxed out on nasal cannula high-flow oxygen plus non-rebreather and she is saturating marginally in the low 90s at best.  I made her daughter aware of these and I also discussed extensively with the daughter when the that the prognosis is guarded in this patient with COVID pneumonia and pre-existing severe chronic obstructive pulmonary disease. Note from 10/11/2021: 10/09/2021 the patient is saturating marginally on 60 L of oxygen per nasal cannula plus non-rebreather however now she is pleasant and cooperative with the medication therefore this is a bit plus compared to yesterday 10/10/2021 the patient is doing a bit better oxygen saturation wise on the same supplemental oxygen she was on yesterday.  She is conversational and speaks in longer sentences before being short of breath.  She refused the Lovenox therapeutic but she is okay with the heparin drip.  Afebrile. 10/11/2021 I consulted virtual intensive care unit, I appreciated very much their input, the patient is not a candidate for intubation given her chronic obstructive pulmonary disease history.  She in fact refused intubation as a concept this morning but then she reconsidered that however after discussing with the pulmonologist the patient again admitted to not wanting intubation and this is in fact inappropriate decision given the advanced emphysema that the patient is suffering from. Noted 30% of predicted DLCO 2 years ago.  Noted persistent oxygen needs of 100% via high-flow nasal cannula 70 liters/minute.  Noted marginal saturation.  As per pulmonologist's recommendation will decrease the steroids to twice daily.  She is off antibiotics since she completed course.  Right now I have her on heparin drip, twice daily steroids, supplemental oxygen.  Prognosis is guarded.