Patient is a 71 y.o. male patient of CNP with history of HFpEF, COPD, CAD, atrial fibrillation on Xarelto presented on 8/20/2023 with hypotension, dyspnea, and generalized weakness. Consulted by MD for ICU transfer of care.    Dyspnea COVID infection Initially requiring 2LNC- back onto RA  Hx of HFpEF, COPD Unclear etiology. Possibly due to hypotension combined with deconditioning.  Minimal symptoms; mostly upper respiratory; denied productive cough CXR negative for acute airspace disease VBG on admission: pH 7.42, CO2 51.4, bicarb 32.9 BNP 3084, approximately baseline  Did not appear to have evidence of AECOPD or HF exacerbation; chronic AC PE less likely Curr   Currently on room air Not candidate from Paxlovid given serious interaction with Xarelto Supportive care only Continue home inhalers  Maintain special isolation ID consulted; remdesivir therapy started -- end date 8/25/23 at night   Hypotension/undifferentiated shock (POA, resolved) Hypotension with BP 70-80/50-60  Per notes from 8/19/2023 he was to start on 8/20 Bumex 4 mg in the morning 2 mg in the afternoon with potassium 60 mill equivalents twice a day, Farxiga 10 mg daily and spironolactone 50 mg daily. Afebrile, no leukocytosis, normal lactate ECG Afib, PVCs; no acute ST-T wave abnormalities Troponin 36, 29 (flat trend) CXR nonacute UA bland Blood cx negative at 48 hrs (8/20)  Likely secondary to hypovolemia due to over diuresis; less likely cardio, septic shock No response IVF bolus in ED; Levophed initiated Admitted to ICU on 8/20; Levophed weaned off 8 pm same day Small alloquats of saline PRN,slow uptitration of diuretics on discharge    Generalized weakness Likely multifactorial, in the setting of over diuresis and hypotension, also component of chronic physical deconditioning; multiple recent hospitalizations  Hypotension resolved PT/OT consulted- PT rec 2-3 days CM for discharge planning-agreeable to outpatient PT/OT so ambulatory referral placed for rehab.  Patient will need On discharge to pick up car from airport.  Per case management this should not be an issue in discussion 8/25   Chronic HFpEF Chronic,  EF 56% BNP 3084, CXR: no evidence of interstitial edema, effusions Home GDMT: Beta-blocker, Aldosterone antagonist, Diuretic, High dose statin, Aspirin, and dapagliflozin  Holding dapagliflozin Resumed BB, statin, aspirin Holding on Repeat TTE.  Last ECHO 7/20/2023 showed EF 56% with mild MVR, pulmonary hypertension, moderately reduced RV function Follows with clinic   Presence of CardioMEMS, implant 12/2021; consulted to check Diureses on hold (limited by hypotention)- slowly titrate back onto on discharge AKI Creat 1.73 Baseline 1.3-1.5 Likely in setting of overdiuresis/dehydration  S/p gentle IVF resuscitation Holding diuretics Creat improving,  has normalized   CAD S/p CABG x 1 LHC (June 2022): 99% mLAD stenosis (unable to wire), moderate RCA disease, 50% proximal OM Patient was transferred with IABP s/p urgent CABG No acute chest complaints at this time Trop elevated on admission (36, 29) but trend was flat ECG w/o acute ST-T wave changes  Likely 2/2 hypotension (see above)  Resume ASA, BB, statin, aspirin therapy   Permanent atrial fibrillation  S/p Afib ablation and LAA ligation 6/19/19 with Dr.  CHADS2-Vasc 3 (Age, CAD, CHF); HASBLED 3-4 Resumed BB; holding diltiazem for hypotension Hrs 80-90s on BB alone Bolus 1L in the setting of hypotension Resume Xarelto   COPD No exacerbation on admit (see above)   Chronic normocytic anemia  Hb at baseline (~ 10) Monitor   BPH Resume flomax given stable BP   Obesity BMI 39