Admission Date: 8/15/2022 Discharge Date: Aug 31, 2022  PRESENTING PROBLEM: Abdominal distention Class 2 severe obesity with serious comorbidity and body mass index (BMI) of 35.0 to 35.9 in adult, unspecified obesity type  Respiratory failure Respiratory failure with hypoxia  Acute ischemic stroke Acute hypoxemic respiratory failure   HOSPITAL COURSE: Patient is a 76 y/o female with a PMH of chronic diastolic HF, moderate aortic stenosis, Afib, CAD s/p stenting, CKD III, type II diabetes mellitus, and COPD on 2L at home who was admitted to the ICU with acute hypoxic respiratory failure and undifferentiated shock. Prior to admission her husband witnessed her lose consciousness and did not feel a pulse. EMS was called and 1 round of CPR was performed leading to return of spontaneous circulation.    Upon arrival to ER, patient was hypoxic, bradycardic, and tachypneic with a GCS of 3. She was intubated for airway protection. Chest X-ray in the ER revealed pulmonary edema and CT thorax showed a patchy right upper lobe density with surrounding ground glass opacities concerning for possible pneumonia. COVID-19 labs were positive. The patient was started on norepinephrine as well as vancomycin and zosyn for possible septic shock as well as a course of decadron for COVID-19 infection. Echocardiography showed moderate aortic stenosis with an EF of 72%. The patient was started on lasix for diuresis to improve the pulmonary edema.    On 8/16, the patient was weaned off vasopressors and extubated to BiPap, however she was subsequently re-intubated later that evening given concern for flash pulmonary edema with acute respiratory failure with systolics in the 200's. Afterwards she was aggressively diuresed and extubation was re-performed a few days later, this time with aggressive anti-hypertensive management with nitro and nicardipine gtt, which have since been weaned and she is now on her home amlodipine, hydralazine, and clonidine. Patient notably had one episode of acute hypoxia following eating food concerning for aspiration. Chest pain workup negative, including CXR, troponins, and EKG. Patient was made NPO and GI was consulted for gastroparesis work up. She was also started on metoclopramide for a 48 hour regimen and restarted on her home coreg for hypertension management.   Throughout her hospital stay, patient also was started on broad spectrum antibiotics later transitioned to Cefazolin for a total of a 7 day course completed today for MSSA infection on sputum culture.   Patient had one episode of hemoptysis following extubation that was thought to be secondary to trauma from tube suction. She was started on TXA nebs and heparin was held, later transitioned to home eliquis for A fib.   Notably she also had one episode of anisicoria for which CT head was performed that ruled out large vessel infarct, MRI brain without evidence of acute lesions.    Following transfer to the floor the patient continued diuresis with IV bumex and was eventually transitioned to oral diuretics. Cardiology continued to follow. She developed recurrent hemoptysis and apixaban was held, and she was started on antitussives as well as inhaled TXA. For covid 19 she completed 10 days of decadron. Oxygen was weaned to 3L NC and CXR showed improvement in infiltrates.  Patient was evaluated by pulmonology due to concern for hemoptysis is and no procedures were performed.  Due to resolution of hemoptysis Eliquis was resumed at the time of discharge and patient tolerated this medication very well.  And she did not develop any hemoptysis in spite of restarting Eliquis.