Narrative:  1/9/23 - Pt presented to clinic with c/o chest tightness and coughing up mucous with a tinge of blood. Pt states he woke up and felt "fullness in his lungs like they are tight." Pt advised to seek care at ED. Pt denied chest pain and SOB. 1/9/23 - Pt presented to ED at 11:37 stating he woke up this morning and was only able to take shallow breaths, states he coughed up mucous and it was pink tinted; denies pain, denies fever, denies SOB, states BP and HR were elevated at time he awoke. ED workup included independent review and interpretation of labs and imaging, reassessment of the patient, and/or cardiac monitoring/continuous pulse oximetry to address the patients signs and symptoms. Patient's initial troponin was elevated 0.33 but there were no EKG ischemic changes and a repeat troponin was 0.31. Cardiology was consulted. Chest x-ray showed minimal pulmonary edema. ABG with an FiO2 of 50%, shows a PCO2 45, and PO2 of 55 mmHg, patient is severely tachypneic, and SPo2 saturation goes down in the 30s when he tries to move out of the bed. In ED, discussed the possibility of intubation with patient but he refused unless he is "crashing." ED course: Nitro-paste placed and IV Lasix given. When Pt stood up, his sats dropped to 66% on room air with a good waveform and he was very symptomatic. Pt will be admitted with primary diagnosis = acute fluid overload with dyspnea and secondary diagnosis = COVID, CAD, ESRD on dialysis, and anemia. Pt was in hospital from 1/9 - 1/14/23. Discharge Summary notes principal diagnosis (reason for admission after study) = (1) Symptomatic Positive COVID-19 with Acute Hypoxic Respiratory Distress Requiring ARDS Protocol; (2) Hypertension, uncontrolled. Additional diagnosis = (3) Hypothyroidism, (4) ESRD: T/TH/S, (5) Anemia of Chronic Disease in Setting of Hx ESRD, and (6) Chronic Kidney Disease Mineral & Bone Disorder (ck-mb). After arrival to ICU, Pt was placed on Airvo. Covid protocol started including treatment with dexamethasone 6 mg for 10 days. Baricinitib for 14 days, cytokine storm labs, daily labs. HOSPITAL COURSE: 75yo M came to the emergency room on 1/9/2023 with chief complaint of acute dyspnea and some chest pressure onset upon awaking. Significant pmhx ESRD (T/TH/Sat), hypothyroidism, HLD, HTN, remote hx of tobacco use. Initially patient considered for admission to a medical-surgical unit. After patient was evaluation by the medicine provider in the ED, the patient's profound dyspnea and clinical presentation warranted the patient to be admitted to the MICU (patient's symptoms in the ER - labored breathing, respiratory rate as high as 35-40 bpm, pox 93-94% on 15 liters on a non-rebreather mask and tachycardia with HR in the 120s-130. COVID 19 screen on admission was positive and upon patient arriving at the MICU, respiratory isolation continued and ARDS protocal initiated. Patient was started on dexamethasone and Tocilizumab. LSTDI status confirmed to be, Full Code. Supportive care and monitoring ensued. While in the MICU, patient was intermittently prone and all pertinent comorbid conditions were managed accordingly. Patient's oxygenation status improved by 1/11/23 and was able to be transferred from the MICU to 4W to continued care management (patient was on AIRVO while in the MICU and by the time of transfer to 4W, he was on 4LNC.) Followed by renal for management of ESRD on HD. Patient received a full 5d course of dexamethasone, was able to be weaned off of all supplemental oxygen by 1/13/23 and found medically stable and cleared for discharge home on 1/14/23. Patient denied any sob, DOE, chest pain, acute discomfort and noted to be ambulating in room with steady gait for several days before discharged. Patient reported that he would be driving himself home. Discharge protocal implemented by nurding. See full chart for details.