ED -- > Hospitalized (11.27.21);  COVID-19 positive (12.2.21);  fully vaccinated HISTORY OF PRESENT ILLNESS The patient is a 62 y.o. male with past medical history significant for hypertension, hyperlipidemia, insulin-dependent type 2 diabetes, chronic obstructive pulmonary disease, former heavy tobacco use and BPH who presents to the emergency department due to poor healing of significant burns on his bilateral calf and feet sustained on 11/7.  His family members encouraged him to present to the ED since burns did not appear to be healing. He was found to be in acute renal failure with severe hyperkalemia as well. He receives most care from (Privacy) and has limited records in our system. Patient originally sustained the burns on 11/07 after immersing his feet in hot water and not realizing the high temperature due to chronic poor sensation from peripheral neuropathy. Skin became red and blistered with subsequent desquamation and significant serous drainage. He treated this with a salve but has not sought formal medical treatment up to this point. His legs have been significantly more red and swollen compared to baseline but eyrthema overall stable in the past few weeks. He also has an ulcer on the heel of left foot which was present prior to burn which has not been formally evaluated. Pain from the exposed superficial skin of burned area has been bearable with Advil QID. He took NSAIDs only sparingly before this incident. He has remained ambulatory but fell yesterday when his legs gave out. He has otherwise felt in his usual state of health and denies any recent illnesses. He is chronically fatigued and always gets "chills" and "tremors" around this time of year but denies fevers. He has poor appetite but drinking plenty of water. Had some dysuria this past week and bilateral flank pain but this has resolved. Remains compliant with daily lisinopril and torsemide. Urine color has remained medium yellow and he denies any  difficulty urinating, decreased urination or hematuria. No abdominal pain, nausea, vomiting (other than some post-tussive emesis), diarrhea, change in chronic dyspnea/cough, chest pain, melena or bloody bowel movements. No etoh or illicit drugs. Recently quit smoking.    On arrival to the emergency department, vital signs notable for blood pressure 184/78 and mild tachycardia ranging 100-110 otherwise vital signs normal.  Labs remarkable for a potassium of 7.8, creatinine 6.04 with a GFR of 10, calcium 7.6 with an albumin of 1.5, hemoglobin 8.5, CRP 69 and sed rate greater than 130. X-ray of the wound over his left calcaneous showed soft tissue ulceration but no osteomyelitis. After hyperkalemia protocol, potassium decreased to 7.1.  Independent review of EKG shows peaked T-waves and midly wide QRS complexes consistent with hyperkalemia.  He received 1 g calcium gluconate, albuterol, insulin/dextrose, Kayexalate 30 g. Admitted to hospital medicine for severe hyperkalemia, acute renal failure and partial thickness burns of lower legs. Found to be COVID positive - PROGRESS NOTE FROM 12.2.21:  Patient febrile to 38.9 C with sudden onset dyspnea and hypoxia to mid 70% on room air requiring 4 L NC to maintain O2 sats >94%. He has productive cough which seems to be worse today per RN. Currently denies chest pain, rhinorrhea, sore throat, loss of taste or loss of smell. Film array positive for COVID 19 Chest xray shows bilateral patchy airspace disease R > L w/ questionable small left pleural effusion. Images most consistent with COVID-19 PNA and likely component of vascular congestion.  Urinalysis without sign of infection Labs show a mild leukocytosis of 12.8 k, new mild AST elevation and stable anemia. Lactic wnl. Procal 1.6 in setting of renal failure Sepsis and acute hypoxic respiratory failure 2/2 COVID-19  -With his renal failure, extremely low albumin and aggressive IVF on admission, suspect there is a good portion of concurrent vascular congestion which will need management with dialysis.  -COVID symptom onset very difficult to determine. When I admitted patient on 11/27, he denied any infectious symptoms and stated that his chronic cough (occasionally accompanied by post-tussive emesis due to coughing so hard) was at baseline. RN only noticed worsening cough in the past 24 hours -- however, appearance of chest xray suggests much longer onset of illness. Moderna vaccins x 2 (March and April 2021). Not COVID tested on admission. -Started dexamethasone 6 mg daily (suspect at least 5-7 days of viral incubation given number of infiltrates on chest xray), Cefepime/azithro for HAP (no vanco due to negative MRSA swab 11/28), follow blood cultures collected 12/1/21. No remdesivir due to renal failure.  -Checking D dimer. Not on VTE prophylaxis thus far due to anemia. Hgb now stable. Start heparin subq TID.