ED - presented with back pain and neck pain of 2 weeks duration.  Back pain is said to be constant in nature, nonradiating, pressure-like, associated with cough and generalized weakness.  Neck pain is also said to be intermittent in nature with stated symptoms above.  Patient denies associated fever, nasal congestion, nausea/vomiting, chest pain, loss of taste, or diarrhea or palpitation.  However, she endorses significant generalized body weakness with inability to ambulate in her home.   On EMS arrival, patient was found with oxygen saturation of 50% on room air which improved to 88% after 15 L of nonrebreather oxygen.  Of note, she received Johnson & Johnson COVID-19 vaccination in March; she is yet to receive a booster dose.  Also, chart review revealed history of indeterminate mass in the medial aspect of the left upper lobe that measured 5 cm with multiple calcified mediastinal lymph nodes. Principal Problem:   Acute respiratory failure with hypoxia (HCC) Active Problems:   Severe Pneumonia, Suspected Bacterial   Acute renal failure superimposed on stage 3b chronic kidney disease (HCC)   Hyperkalemia   Pneumonia due to COVID-19 virus     ASSESSMENT/ PLAN: # Acute Hypoxic Respiratory Failure due to COVID Pneumonia  Continue oxygen therapy to maintain adequate saturation  Full barrier isolation + symptomatic management?acetaminophen as needed for pain/fever, antitussive as needed for cough IV dexamethasone 6 mg daily initiated SABA as needed for shortness of breath + serial blood gas monitoring  Follow up serial acute reactant protein monitoring + BNP; will obtain TTE with elevated BNP Empiric antibiotic initiated with ceftriaxone and azithromycin in view of elevated pro-calcitonin Empiric Heparin anticoagulation initiated in view of elevated D-dimer of 7.66 with inability to further evaluate for pulmonary embolism [renal status]; possible VQ scan as per primary team once patient is stable  Possible ID evaluation as per primary team for further management recommendations  Monitor for respiratory distress + overt infection   #Acute on Chronic renal failure with Hyperkalemia Serial renal function monitoring + renal ultrasound Hyperkalemia protocol initiated Continue telemetry monitoring for cardiac arrhythmia Serial electrolyte monitoring and correction Nephrology evaluation for further recommendation Strict I/O + monitor daily weight   All nephrotoxic medications presently on hold   # Pulmonary Nodule- stable    # Hyperlipidemia + Hypothyroidism + CVA To resume other home medication as per comorbidities following medication reconciliations      1/17/2022 PRONOUNCED DEAD AT 9:17 AM 5:18 AM NOTE Patient's SpO2 consistently in 70's and 80's this morning despite compliance with BiPAP at FiO2 100%. She is very lethargic.    I spoke with daughter in law Her on the phone with an interpreter. We discussed that patient is dying and the aggressive cares we are doing is not going to change that. We agreed that she would want most to be as comfortable as possible so we will now focus our cares on comfort only. This includes removing the BiPAP because she has consisently expressed discomfort using it.   1/16/2022 NOTE 4:18 PM I received communication with RN about worsening resp. Status. We changed her to BiPAP at 100% barely maintaining sats in High 80's. Stat CXR ordered. Need PICC line and discussed with IR as well. Started on Ativan, Morphine for resp distress. Updated family, wants to continue with BiPAP. 1/14/2022  NOTE  She is mostly unchanged.  Continues to gradually get weaker every day.  This morning she was requiring 100% FiO2 on high flow nasal cannula.  Tachycardic and tachypneic.   1/13/2022 Hgb 6.4 this morning. Patient is confused and unable to give consent. I spoke on the phone with her grand-daughter and her daughter-in-law, they gave verbal consent. Will proceed with transfusing 1 unit PRBC's.   1/11/2022 currently at 100% FiO2 on HFNC.  No other changes noted hemodynamically.  We will continue to use HFNC to keep O2 sats above 87. 1/10/2021 NOTE No changes noted.  She does respond to commands appropriately.  Oral intake on the lower side.  No issues or complaints noted otherwise.  Hemodynamically worsening O2 requirements noted.  Slightly tachypneic with respiratory rates in the low 20s.