Patient is a 72 y.o. male of MD with history of rheumatoid arthritis, mitral valve regurgitation, hypertension, hyperlipidemia, CAD s/p CABG, atrial fibrillation, HFrEF with improved EF and recent COVID infection presented to the hospital with altered mental status and shortness of breath.  He developed increasing oxygen requirements requiring high flow nasal cannula and eventually intubation on 2/1.  Respiratory failure due to multifocal pneumonia, possible volume overload on background of lung disease from recent COVID infection. Completed 7-day course of Zosyn on 2/4. Briefly extubated on 2/5 however required reintubation.  On 2/11 developed worsening hypotension, tachycardia and increase in inflammatory markers being started on broad-spectrum antibiotic for likely HAP.  S/p trach/PEG 2/13.   Acute respiratory failure with hypoxia Found to be hypoxic requiring 2 L nasal cannula at outside ED Thought multifactorial to a combination of edema, pneumonitis and recent COVID infection Increased oxygen requirements after admission requiring HHF and subsequently intubated on 2/1/23 Extubated and reintubated on 2/5 after developing increased work of breathing CT chest abdomen pelvis with contrast 2/11: Moderate marked bilateral pulmonary infiltrates Completed course of decadron Failed vent weaning due to mental status S/p Trach/PEG 2/13 Vent needs improving, tolerating PSV trials well, anticipate that he can be liberated from the vent over the next 1-2 weeks while at Select   Toxic Metabolic Encephalopathy Reportedly had some AMS prior to presentation, but A&Ox 3 on presentation Course complicated by respiratory failure requiring intubation/sedation Has had agitation with sedation wean while intubated Now off of sedation, he is alert, trying to communicate via writing messages but nonsensical, suspect he has ongoing delirium Continue scheduled seroquel and oxycodone   Sepsis Hypotension HAP BP as low as 81/56 at outlying ED, lactic acid 4.1 Hypotension thought secondary to sepsis although possibly due to medication Chest x-ray: Diffuse bilateral lung infiltrates, stable when compared to recent on 1/3/2023 Echo 11/2022: EF 58%, mild LVH, improved LV function when compared to prior Repeat Echo with EF 35%, severely enlarged LA in the setting of afib with RVR Completed 7d course of zosyn on 2/4 Hypotension and rising WBCs on 2/11; CT chest with persistent bilateral pulm infiltrates Blood cx from 2/11 with NGTD Sputum cx with growth of Serratia marcescens; pansensitive MRSA probe neg, stop Vanc Cefepime narrowed to ceftriaxone, continue through 2/18   Urinary Retention Failed TOV on 2/13 Attempted straight caths but had difficulty with some bleeding Foley replaced 2/14 Will need to re-attempt once able to mobilize   Acute on Chronic HFpEF Echo 11/2022: EF 58%, mild LVH, improved LV function when compared to prior BNP 8860, increased from 2752 two weeks prior Chest x-ray: Diffuse bilateral lung infiltrates, stable when compared to recent on 1/3/2023 Repeat Echo with EF 35% in the setting of afib with RVR Cardio consulted, discussed adding beta-blocker if pressure tolerates Good response to lasix over 3L out 2/2 - 2/3 No need for further diuresis at this time   Recent COVID infection Symptom onset 1/7/2023, tested positive on 1/12/2023 Vaccination status: Vaccinated Was outside of window for Paxlovid but treated briefly with Decadron Completed 20d isolation on 2/1 Completed a long course of IV decadron   AKI Serum creatinine 1.42 on admission Baseline appears to be 0.7?0.9 Cr stable at baseline   Transaminitis AST 156, ALT 163 on admission, Transaminases elevated in the setting of hypotension and shock liver LFTs now trending down, nearly normalized CAD  Atrial fibrillation Hypertension s/p CABG S/p cardioversion in 6/2022 Was on amiodarone and carvedilol as an outpatient; amio stopped due to elevated LFTs, was not effective at rhythm control previously Transition off heparin gtt to eliquis HR intermittently elevated Increase metoprolol to 50mg BID (on coreg at home but due to soft Bps doubt he will tolerate) Holding home lisinopril and lasix due to low normal BPs   Rheumatoid arthritis Home plaquenil and methotrexate held on admission Resumed home prednisone 10mg BID and plaquenil Continue hold methotrexate