Patient is a 79-year-old female with a past medical history of severe COPD, hypertension, chronic low back pain, CAD, hypothyroidism, tobacco use who presents with altered mental status and shortness of breath.     History is provided by patient's son who was present at the bedside.  Per their reports, patient has a history of severe COPD, has been told she has 6 months to 1 year to live by her pulmonologist.  Has had clinical decline over the last several weeks.  Patient lives by herself, her sons check on her and help her as much as they can.  Over the last several days they have noticed that she has not really been getting up off of her chair.  She has been drowsy and has been having difficulty feeding herself or drinking any fluids.  They did notice that her breathing has been steadily getting worse however this has been an ongoing problem over the last year.  Today they found her minimally responsive and called EMS.  On arrival to ED patient was hypothermic with temperature of 92.7.  Tachypneic with 25 respirations, heart rate 73, SPO2 96% on NRB and BP 124/65.  Patient has a BMP which shows creatinine of 1.56.  CBC shows a stable chronic anemia.  Lipase, lactic acid, troponin are within normal limits.  Initial ABG showed pH of 7.27, PCO2 66.4, PO2 84, bicarb 30.4.  She was placed on BiPAP, repeat ABG showed PCO2 had improved to 60 with pH of 7.29.  Chest x-ray reveals mild blunting of the costophrenic angles but otherwise no acute process.  She is positive for COVID-19.  During her ED course she became progressively hypotensive despite 30 cc/kg sepsis bolus.  She has been placed on Levophed gtt.  Plan was discussed with the patient's family at the bedside.  They did state that she would not want CPR or life-saving measures but would be okay with intubation if it was to be for a reversible cause.  Patient has received broad-spectrum antibiotics, admitted to ICU for management of septic shock, COVID-19 and respiratory failure.   Clinical Summary The following problems were addressed during this admission:   Septic shock SIRS positive with hypothermia, tachypnea.  initially required pressors. Sputum cultures negative; urine culture with Klebsiella; blood culture 1 of 2 with MSSA; cefazolin sensitive. Septic shock was attributed to combination of COVID-19, and likely bacteremia from staph.  initially treated with broad-spectrum antibiotics but narrowed to ceftriaxone by day of discharge.   MSSA bacteremia  noted to have 1 out of 2 bottles on 11/20,  MSSA which was pansensitive,  echo did not show any concerning signs or vegetations.  low concern for endocarditis.  but given severity of illness will treat for 2-week course  of outpatient antibiotics which will complete later this week with ceftriaxone.  Dr. to follow  patient therapy,  should follow-up with PCP to continue to monitor if concerning signs  following therapy.    Acute on chronic hypoxic and hypercapnic respiratory failure AE COPD COVID-19 positive Patient with history of gold stage D COPD, presented with ABG showing pH 7.27, PCO2 66.4, PO2 84, bicarb 30.4.  initially required BiPAP,  and respiratory status steadily increased,  initially required short course of Decadron and remdesivir. back to baseline home O2 by day of discharge.   Metabolic encephalopathy Delirium In the setting of septic shock and hypercapnia, Which has improved but still had persistent delirium.  was started on Zyprexa at night and trazodone to help regulate sleep cycle.  ?  will discharge with trazodone 100 mg which she has gotten for the past few days   AKI on CKD stage III Creatinine 1.56 up from baseline of 1.1-1.2.  In the setting of septic shock, resolved.   Hypothermia Environmental + sepsis.  Temperature 92.7 on presentation, improved with Bair hugger.  resolved   Hypothyroidism  continued on home medications   Hypertension  metoprolol was held throughout this admission, has not required antihypertensive throughout so we will hold discharge.  Can be restarted by PCP if indicated as an outpatient.   History of CAD Diffuse nonobstructive CAD on 2019. no issues while admitted.   Chronic anemia ? Hemoglobin stable at 10.9. ? Anemia of chronic disease + renal disease   Diarrhea noted to have chronic diarrhea following abdominal surgery,  does not appear to be worse than baseline.  often associated depending on what she eats.  -  can continue loperamide as needed   Rib fracture Right side rib fracture noted on 11/14 at OSU.  - Conservative management   Discharge diagnosis Septic shock  MSSA bacteremia Acute on chronic hypoxic and hypercapnic respiratory failure AE COPD COVID-19 positive  Metabolic encephalopathy Delirium AKI on CKD stage III