Admission Date: 3/5/2023 Discharge Date: Mar 12, 2023 PRESENTING PROBLEM: Acute on chronic respiratory failure with hypoxia Respiratory failure with hypoxia Multifocal pneumonia  Hypoxia    HOSPITAL COURSE: 83 y.o. male who presents with a history of proximal AFib on Eliquis, coronary artery disease s/p biventricular pacemaker and ICD, HFrEF, CKD 3B, BPH, mild cognitive impairment, presented to outside hospital with chief complaint of respiratory distress and confusion.  Patient had recent hospitalization from 01/12-1/20 with femur fracture of his left side which was surgically repaired and patient was discharged to subacute rehab.  Patient was discharged from subacute rehab 2 weeks ago and returned home where he lives with his caretaker who is his DPOA.  Per DPOA patient likely contracted a respiratory virus at subacute rehab as he was experiencing symptoms since.  He presented to Hospital due to worsening respiratory symptoms.   In the outside emergency department patient is positive for COVID and was given IV fluid and Zosyn for concern for sepsis.  Patient initially required BiPAP but hypoxia improved after 80 mg of Lasix was given and per RN patient diuresed around 2500 mL overnight.  Patient initially had a lactic acidosis which downtrended resolved.  Patient was transferred to Hospital for further evaluation management of this acute hypoxic respiratory failure   CT abdomen pelvis due to concern for abdominal pain which showed no acute intra-abdominal findings.  A CT angiogram of thorax was obtained which showed large bilateral pleural effusions and consolidative opacities concerning for multifocal pneumonia possibly return aspiration.  Of note there was contrast noted on the right side of the heart along with hepatic circulation concerning for massive PE versus missed timing of IV contrast.   Of note, bilateral lower extremity Doppler ultrasounds were negative for DVT. Echo showed EF 25-30% and severely reduced LV function, and moderately decreased RV function.    Patient admitted to the hospitalist service and thoracentesis was attempted and ended up being aborted due to patient positioning and agitation.  He was moved to the intensive care unit due to increasing oxygen demands requiring 100% high-flow mas and eventually BIPAP.  Due to persistent hypoxia elevated oxygen requirements medical intensive care unit team took over as primary with plan to trial diuresis prior to evaluating for thoracentesis.  After diuresis, the patient showed significant improvement in respiratory status. NT BNP on admission >59,999. Respiratory failure was thought multifactorial but most likely attributed to volume overload due systolic heart failure with pulmonary edema, as well as some component of covid 19. He was treated with a course of decadron due to covid.  He did show worsening mental status with frequent waxing and waning in his level of awareness and ability to follow commands.  No focal neurological deficit. Electrolyte, B6, B12, TSH unremarkable. Kidney function at baseline.  No history of liver failure. Fluctuating awareness likely secondary to dementia with metabolic encephalopathy.  Due to progressive weakness, metabolic encephalopathy superimposed on suspected vascular dementia, dysphagia requiring pureed diet with poor po intake, palliative care was consulted. DPOAH activated. Care conference was completed on 3/10 with plan to continue aggressive care until discharge, then discharge home with hospice on 3/12.