Death Note: Date of Admission  11/08/2021   Date of Discharge  11/30/2021   Reason for Hospitalization   Severe COVID-19 PNA  Hospital Course   Patient was a 68 yoM with OSA, ICCM w/ HFrEF 35%, VT s/p AICD on amiodarone, DM2 (newly diagnosed), HTN, and HLD who was initially admitted to the MICU on 11/8 for acute hypoxemic respiratory failure 2/2 COVID infection. In  ED, CT C/A/P was performed with his CT Chest showing signs of multifocal PNA c/w Covid. Initial labs were significant for leukocytosis, elevated D. dimer, AKI (Cr 2.89), HAGMA,  transaminitis, and elevated bilirubin; admitted to MICU for management. Patient was initially on NIPPV but subsequently intubated on 11/8. S/P on Remdesivir/dexamethasone/tocilizumab x1.  Hospital course c/w ongoing hypoxemia requiring bronchoscopy (11/14), RPP growing Serratia and klebsiella, s/p ertapenem. Persistent hypotension requiring initiation of stress dose steroids w/ hyperglycemia requiring initiation of insulin drip. On 11/14, the patient went into shock requiring multiple pressors. Due to shock he had ARF and nephrology was consulted; initiated HD on 11/15-11/18. ST elevation on telemetry 11/16 concerning for inferior MI, likely demand ischemia. Max troponin 55 (on admission 35). Vancomycin and meropenem added 11/16 due to shock and leukocytosis with positive QTL on 11/15 for serratia, but deescalated back to ertapenem. CT abdomen 11/20  with concern for pancreatitis noted findings of acute pancreatitis with small amount of ill-defined peripancreatic fluid, lipase was normal.  Palliative care consulted and were following.  Goals of care conversation had on 11/22 with patient's brothers and daughter.  Decision was made to have daughter as the primary decision-maker.  Decision from goals of care conversation was to make patient full code and proceed forward with disease oriented treatment.  Plan from family would be to continue ventilator treatment with plan for tracheostomy and PEG tube when appropriate.   Septic picture with RUQ US concern for obstructive stone vs infected stone, GI consulted for possible ERCP but not planning intervention at this time. ACS was consulted for concern of cholecystitis, they reviewed and recommended HIDA scan. HIDA scan was completed with no obstruction of the cystic or common bile duct, there was no evidence of cholecystitis, likely passed stone that was noted on ultrasound.  Concern with decreasing platelets that patient could have HIT, d/c heparin and placed on argatroban drip for DVT of RIJ. Heparin PF4 lab and unfractionated heparin were negative. Patient did develop some tachypnea on ventilator 11/26, fentanyl drip was restarted.  On 11/27 decreased tube feeds to 30 cc/h due to emesis overnight with feeds and free water flushes. Held tube feeds again on 11/28 after emesis.   11/27: Consulted ACS for trach and PEG (consider J-tube based on recent emesis) placement however patient on pressors and still requiring too high level of oxygen.  Placed right femoral triple-lumen cath.  11/28: trial of dobutamine drip cause more hypotension so this was held, started on vasopressin overnight due to worsening hypotension  11/29: significantly worsening respiratory status with O2 sats in mid to low 80s on 100% FiO2 on vent; P/F ratio 51; increasing sedation with versed and trial iNO; poor response to PEEP increase; concern patient remains intravascularly depleted; concern for aspiration pneumonitis   Daughter, was updated about declining prognosis at bedside on 11/29 during rounds. Questions were answered. Patient significantly worsened on 11/29, was requiring three IV pressors and unable to maintain adequate BP. His oxygenation drop to around 80% with 100% FiO2 on the vent and had minimal imporvement with more sedation and iNO. Family notified again in the evening on 11/29, patient made DNAR. Family elected to continue treatment for ~24 more hours and then would consider comfort care. Patient passed on 11/30/21 at 0937.  Discharge Diagnoses      COVID-19  Severe Acute Hypoxic Respiratory Failure on mechanical ventilation  Severe hypotension and shock, requiring three IV pressures  Aspiration pneumonitis