Presented with a significantly acutely ill picture in acute hypoxic respiratory failure secondary to Covid infection, also with acute on chronic systolic heart failure exacerbation.  She received 2 doses of IV metoprolol with no subsequent drop in her blood pressure and transient.  Improvement in her rate down to the 120s to 140s, however she resumed rate back up to 150s to 170s. She clinically appeared fluid overloaded along with a chest x-ray demonstrating pulmonary vascular congestion and pulmonary edema, was initiated on 15 L nonrebreather which was required to maintain her 02 sats above 92%. To attempt for rhythm control, we have bolused her with IV amiodarone which was unsuccessful, she is now initiated on an amiodarone drip. For her fluid overload we also began treatment with 80 mg of IV Lasix. Her blood pressure did remain stable throughout her ED course. Did not escalate above need for 15 L nonrebreather and her work of breathing did seem to improve mildly after receiving IV Lasix. VBG shows chronic respiratory acidosis with appropriate compensation. Lactate mildly elevated. Due to concern for sepsis she received IV vancomycin and cefepime. For Covid she was treated with 6 mg of dexamethasone. Did desire to obtain CT chest PE, however patient is allergic to IV contrast with anaphylaxis and we will defer as her symptoms are most consistent with Covid and she had an improving symptomatic course with treatment. I discussed this case with the medical ICU fellow who advised that this patient should be admitted to the medical ICU for further care and management.  On arrival to MICU, pt's respiratory status initially improved with diuresis (given 80 IV lasix in ED) and she was on 10L NC. She stated that her symptoms began 5 weeks ago after her husband tested positive for COVID-19. She stated that she normally uses 2-2.5 L NC at home & BiPAP at night and had increased up to 4L NC at all times over past several days. She has never had a blood clot before. She is on Xarelto but reports missing a few doses and previously reported being off of it entirely in November due to bruising. For her COVID-19 she was started on a 10 day course of dexamethasone ( 12/24-01/02), 14 day course of Bari (12/24- 1/6). Due to concern for potential PE, 4 extremity dopplers were obtained demonstrating L Popliteal DVT and superficial cephalic thrombosis in RUE. Patient was subsequently placed on therapeutic lovenox ( 12/24 ). TTE obtained demonstrating normal LVEF (55-60%) and unchanged RV dilation. Given concern for volume overload exacerbating respiratory symptoms patient was diuresed. She had escalating 02 requirements requiring optiflow/BiPAP. For her AFIB with RVR, her metoprolol was up-titrated and she was transitioned from Amio gtt to PO on 12/25. On 1/2 she was noted to have rising WBC and increased productive cough, so was started on vanc/cefepime empirically for HAP. Sputum cultures ultimately grew pan-sensitive P. aeruginosa. She experienced significant hyperactive delirium throughout MICU course, and required precedex gtt. Patient refused BiPAP and had a good understanding that if her oxygenation were to worsen, she was likely to pass away. After significant goals of care discussion, patient was transitioned to full comfort care and passed away.