The patient  reports that Sunday 10/3/21 he had low grade fever, cough, chills and shortness of breath.  On Monday 10/4/21 he came to the ER at Erlanger East for evaluation.  Initial vital signs with pressure 214/65, heart rate 64, respiratory rate 20, temperature 99.4, oxygen saturation 84% on room air.  His white blood cell count was 17, rapid COVID-19 test negative, creatinine 1.6 (baseline 2.3), sodium 122.  CXR with infiltrates.  Patient was admitted on Rocephin and Zithromax.  Blood cultures drawn on 10/4/21 remained negative.  Evaluated on 10/5 he reported that he was feeling much better.  Sodium was improving up to 127 and creatinine remained around baseline.  The patient was able to go down to room air and he was saturating above 90% on room air until 10/8 when he required oxygenation.   He was still hypertensive and he was placed on Procardia XL and metoprolol although he just got 2 or 3 doses of the beta-blocker due to bradycardia.  On 10/8 the patient started worsening clinically.  He had hallucinations and he became hypoxic that morning at 88% on room air therefore he was placed initially on 3 L nasal cannula.  A repeat confirmatory COVID-19 test was ordered.  Repeated CT scan demonstrated some improvement on infiltrates with some edema however clinically the patient was worse and he became more confused agitated and disoriented.  CT scan of the head did not show any abnormalities.  His sodium got low again.  His D-dimer was elevated but he could not have CTA done due to renal function and he was not stable to lay flat for VQ scan so he was a started empirically on heparin drip.  Antibiotics were broadened to Zyvox and cefepime.  The patient had alternating periods of encephalopathy and being fully alert and oriented. On 10/9 the patient was placed on Vapotherm 40 L 100% FiO2 but throughout the morning he was able to go down to 70% FiO2.  His renal function got significantly worse and he also developed hyperkalemia.  His confirmatory COVID-19 test came back negative and his sodium continued to get worse again.  Pulmonary and nephrology at East saw the patient and he was a started on bicarb drip.  Overnight from 10/9 into 10/10 the patient was having Kussmaul respirations around 40 times per minute, diaphoretic, not following commands, heart rate in the 30s blood pressure with systolic in the 100s.  Lactic acid was around 10.  He was more encephalopathic and with decreased responsiveness.  He developed bradycardia in the 20s and received 1 dose of atropine plus Levophed.  The patient was intubated and transferred downtown.  Critical care concluded that his respiratory failure was mainly due to volume overload due to worsening renal failure.  The patient was a started on CRRT for volume management.  Patient also was found having shock liver although he did not have significant hypotension but he was significantly bradycardic.  Hepatitis panel and all the testing for check liver etiologies came back negative.  Patient was able to be extubated on 10/13.  Nephrology recommended continuation of hemodialysis.  His bradycardia improved.  He was transferred to the floor eventually.  His encephalopathy was a slowly resolving.  On 10/19 he had a permacath for dialysis.  Patient is going to be discharged to inpatient rehab and he will continue dialysis 3 times per week. He will likely need HD long term