Patient is a 61 y.o. female patient of DO with a history of end-stage COPD, HFpEF, HTN, prediabetes and squamous cell carcinoma s/p resection (2014) who presented to the ED from hospice for shortness of breath. Recent admission for MRSA pneumonia, as well as new pulmonary nodules that were found to be recurrent squamous cell carcinoma. Pt was seen by palliative care at that time for help with pain management, constipation and shortness of breath. Patient noted to be hypoxic in low 60s on EMS arrival. Requiring NIPPV support and Covid positive on admission. Palliative consulted for symptom management. Initially on BiPAP; patient had clinical improvement with steroids and breathing treatments. Remained stable on heated high flow 65%/55L and eventually transitioned to 10LNC. Found stable for discharge home with home hospice on 11/10/22.   Discharge Diagnoses: Acute on chronic hypoxemic respiratory failure COVID PNA AECOPD Etiology: AECOPD from Covid pneumonia Recent admission for MRSA pneumonia, recurrent SCC 12LNC baseline due to severe emphysema/end-stage COPD/lung cancer Discharged with home hospice at last admission Found by EMS hypoxic in low 60s Requiring BiPAP 14/6 50% at this time VBG improved with NIPPV, initial severe respiratory acidosis/CO2 retention CTPA 11/7/22: No PE, bilateral infiltrates concerning for multifocal pneumonia, emphysema Noted chills and dry, nonproductive cough for past few days Denies fevers, myalgias, URI symptoms   ? Treated for AECOPD with methylprednisone 40mg Q8H for 3 days, transitioned to daily prednisone 20mg for 10 days, then 10mg for 10 days. Daily azithromycin 250, duonebs and symbicort.   ?Pain/dyspnea regimen per palliative:             Oxycodone 20mg Q4H Oxycodone 10 mg every hour PRN breakthrough pain and/or dyspnea Flexeril 5 mg TID Gabapentin 600 mg TID Senna-S 2 tabs BID Miralax 17 gm BID Atarax 25 mg with melatonin 5 mg at bedtime -ID consulted; not a candidate for monoclonal therapy -Remdesivir given 11/8. -Covid cocktail, CRP moderately elevated 44 -Procal/ferritin ratio not consistent with bacterial pneumonia -IS/PEP therapy -Given her severe COPD, >86% O2 is acceptable for her -Can use lidocaine patch on chest wall for pain, also give pillows so patient can better brace herself when she coughs -Respiratory PCR panel covid positive; Procalcitonin and urinary antigens negative. MRSA probe positive. Right-sided squamous cell carcinoma status postresection Recurrent squamous cell carcinoma of right lung Right upper lobe nodule Diagnosed 2013, s/p RLL resection 2/2014 Followed by Dr.  CT 9/2022: Increase size of the 2 right upper lobe irregular solid noncalcified pulmonary nodules or nodular infiltrates when compared to CT 8/6/2022 NM whole-body bone scan 9/27 showed no scintigraphic evidence for osseous metastatic disease MRI brain with and without contrast performed 9/27 showed extra dural lesion on the right temporoparietal region that could represent calcified meningioma versus bony osteoma Pathology 9/28/2022 right lung nodule core biopsy: Non-small cell carcinoma.  Most consistent squamous cell carcinoma.  Gene testing resulted 10/07 for positive PD-L1    -Pain/dyspnea regimen as above -GOC discussions as below   Goals of care Reviewed code status and prior discussions with palliative care.  Confirmed with patient 11/7/22 Full code at this time with intubation Patient expressed that she would not want prolonged ventilator support No changes at this time, but patient and her family will benefit from ongoing discussion.    ? Home hospice   Tobacco abuse disorder ?Encourage complete cessation ? Nicotine replacement therapy