Hospitalized (9.11.21 - present);  COVID-19 positive;  Fully Vaccinated  History of Present Illness Patient is a 85 y.o. male with a history of HTN, paroxysmal atrial tachycardia and prostate cancer s/p prostatectomy who presents today with cough and shortness of breath.  Symptoms started about a week ago and patient thought he had a mild head cold with congestion, rhinorrhea, and headaches. His symptoms continued throughout the week, but he noted they were "up and down" and he initially felt he was improving. However, he then began to have more shortness of breath and coughing. He tested positive for COVID on 9/10.  Shortness of breath worsened, prompting ED presentation. Initially planned for monoclonal antibodies, but he then became hypoxic and was placed on 3 L NC. CXR showing bilateral groundglass opacities suggestive of COVID. WBC 14.3. He was given decadron and hospitalists were asked to admit for further care.  Chief complaint COVID-19   Assessment and Plan Covid-19 pneumonia Acute respiratory insufficiency with hypoxia - symptom onset about 1 week ago - (+) PCR 09/10 - fully vaccinated with Pfizer (2/25/21 and 3/25/21) - Chest xray consistent with COVID pneumonia - started on decadron - start remdesivir - supportive measures - prone positioning - daily labs   Leukocytosis - WBC 14.3 - will check procal - trend CBC - hold off on antibiotics for now  Progress note 9.20.21: This is a 85 y.o. who has a past medical history significant for remote history of Prostate Cancer s/p Resection, HTN, who presented to the ED 9/11 with dyspnea, testing positive for COVID on 9/10, was admitted for hypoxia and started on dexamethasone/remdesevir 9/11, and empiric antibiotics on 9/13. His oxygen requirement has worsened and Pulm/Crit Care was asked to see for his respiratory failure. He ultimately worsened and required transfer to the MICU. D-Dimer significantly elevated, superficial clots seen in upper extremities.   Key Plan for Today September 20: Continue high-flow nasal cannula oxygen/non-rebreather face mask At high risk for requiring intubation/mechanical ventilation Begin amiodarone for atrial fibrillation with RVR Decadron day 10/14 tentative course Continue empiric heparin drip given superficial clots and markedly elevated D-dimer  Status post empiric ceftriaxone/azithromycin through September 17 Fluid balance -400/24 hours -- > goal even to negative fluid balance, as tolerated Advanced diet, as tolerated Add Pepcid, given steroids and anticoagulation  Acute respiratory failure with hypoxia Assessment & Plan 2/2 COVID Pneumonia despite vaccination. Question additional issues, maybe some reticular changesin the bases bilaterally - Continue HFNC + NRB Mask and wean for goal sats>90%. At significant risk of decompensation requiring intubation - Completed empiric antibiotics, started 9/13 for 5d course.  Procal is low - UE dopplers with superficial clots, question PE given elevated D-Dimer, starting empiric heparin gtt. Echo Pending. Hold on CTPE for now given tenuous status - Continue intermittent lasix for euvolemia   Pneumonia due to COVID-19 virus Assessment & Plan - despite vaccination, very ill, no evidence of immunocompromise. Tested positive 9/10 - Continue dexamethasone, started 9/11, expecting 10d course, will extend depending on his trajectory - s/p remdesevir 5d, started 9/11