Hospitalized; COVID-19 positive (8.29.21);  (fully vaccinated);  hospitalized on 8.29.21 - still hospitalized.    HISTORY OF PRESENT ILLNESS: Patient is a 72 y.o. female who presents today with acute encephalopathy.  Patient has a past medical history significant for type 2 diabetes, dementia reportedly alert oriented x2, TIA, CVA, DVT, history of a meningioma status post resection, history of renal cancer status post right nephrectomy, kidney stones.  Per chart review and discussion with doctor patient has had decreased oral intake recently and with increasing nausea and vomiting over the past 2 days.  She has continued to take her medications per report from doctor.  She presents to the emergency department with new AKI baseline creatinine 0.4 presenting creatinine 4.6.  She had leukocytosis to 17. She was minimally responsive with a GCS of 6 pH of 7.18 with significant metabolic acidosis.  Significant elevated lactates 9.3 and a new urinary tract infection.  I personally discussed with patient's daughter that she is to be full code and this is in concordance with Dr. note from 8/29.  Initially the MICU was consulted for close electrolyte monitoring and severe metabolic acidosis however given worsening lactates arterial line surgeon and persistent care MICU took over as CC1.  A arterial line was placed in the right radial arm.  Lactates continue to up trend without any obvious evidence of ischemia.    Patient is a 72 y.o. female w/PMH of Dementia (A&O x 2), + COVID 19 (12/2020), DVT on Xarelto 10 mg, HTN, HLD, T2DM, R. Meningioma s/p Resection (2009) s/p Left Hemiplegia, Renal Cell Carcinoma s/p Right Nephrectomy (1/15/2013), Head Trauma as a child when she was hit by an Ax, inpatient since 8/29/2021 with /AMS, Metabolic Acidosis, Hyperkalemia, UTI/Sepsis (on Cefepime and Flagyl), + COVID 19, Prolonged QTc > 520. EEG was obtained, neurology was consulted per EEG burden and in setting of Pt's Hx of Meningioma resection concerning about started AED or getting an MRI.  Acute kidney injury History of right nephrectomy Severe  metabolic acidosis In May of 2021 was 0.4.  Presenting creatinine today 4.51.  Unclear precipitating cause.  But likely secondary to decreased oral intake in setting of nausea and vomiting.  Subsequent severe metabolic acidosis secondary to acute renal failure and lactic acidosis.  No obvious evidence of obstruction or hydronephrosis on CT scan. -nephrology consult appreciate input -D5 sodium bicarb drip -status post 3 amps of sodium bicarb -urine lytes pending, -VBG and lactates Q 3 -low threshold for renal replacement therapy -avoid nephrotoxins   Sepsis Urinary tract infection. Leukocyte esterase positive on urinary analysis.  Complex patient given renal failure in significant lactic acidosis and altered mental status.   -metronidazole, cefepime -blood cultures pending   Tachycardia EKG with RBBB, unclear if new Will pull trops.   Lactic acidosis Unclear cause no obvious source of hypoperfusion on examination.  Art line with good pressures.  Systolics have been greater than 160. She appears well perfused throughout.  No significant abdominal discomfort on exam.  Lower extremity DVT ultrasounds did show evidence of left popliteal artery occlusion.  Will obtain lower extremity arterial duplexes.  Other considerations include metformin accumulation in the setting of her AKI, or worsening lactate in the setting of albuterol administration. -monitor lactates Q 3 -monitor VBG - -obtain arterial duplexes to rule out critical limb ischemia -low threshold to consider CT abdomen pelvis to evaluate for ischemia.   Hyperkalemia-improving Given acute renal failure -status post low,, Lasix, insulin dextrose, albuterol.  Improving BMPs q.4 until stable Close I&Os   Altered mental status Likely secondary to combination of the above toxic metabolic encephalopathy from AKI, sepsis, urinary tract infection, acidosis.  CT head negative on arrival. EEG   COVID 19 Previously had COVID back in December of 2020 No current respiratory issues.   History of DVT Previously on Xarelto -consider heparin gtt.      Lines-art line DVT prophylaxis-on Xarelto at home, heparin drip Diet-NPO Code status-full Antibiotics metronidazole, cefepime Disposition-anticipate greater than 2 midnight stay in the intensive care unit for close electrolyte monitoring.