Patient is a 79 y.o. female patient of MD with history of HTN, HLD, hypothyroidism, recent COVID diagnosis who presented to Hospital with weakness, fatigue, shortness of breath. Admitted to obs at hospital 12/29-12/30 for chest pain and sent home with Paxlovid.  She was found to be in acute hypoxic respiratory failure which acutely worsened requiring intubation and ventilator support from 1/2?1/5.  Completed course of antibiotics and diuresed for treatment of acute heart failure.  Cardiology and pulmonology evaluated.  Acute heart failure exacerbated by atrial fibs/flutter for which she was started on rate control and anticoagulation.  Course was complicated by in-hospital delirium which is since improved.  PT/OT evaluated with recommendation for SNF versus IPR placement however patient declined placement in favor of home health.   Acute respiratory failure with hypoxia O2 sats in the 89-90% in the ED with tachypnea in setting of COVID infection with possibly pneumonia and  CHF exacerbation.  Initially required 2L NC on admission.  Worsening oxygenation on day 1 of admission requiring initiation of nasal oxymizer- 13L, later further deterioration lead to intubation on 1/2/23.  Extubated to NC on 1/5/23, weaned to room air on 1/6  Current O2 requirements: Room air Pulm/CC followed.  Management as below   Atrial fib/flutter Started 1/4/23, looked more like flutter on tele. EKG with atrial fibrillation. HR controlled (70-80). TTE 1/6/2023: EF 45+/- 5%, global hypokinesis of LV, moderate aortic regurg Resume home metoprolol, dose increased for better rate control. Eliquis started given high CHADSVASC score.  Cardiology evaluated, now signed off Monitor on tele.    Acute on chronic combined systolic and diastolic heart failure CTPA on 12/29 did not show any PE, showed mild scattered atelectasis and peribronchial thickening CXR on admission showed interval development of bibasilar atelectatic/consolidative changes, left greater than right; small bilateral pleural effusions; central vascular crowding/congestion. NT pro BNP of 3771 Last TTE (12/12/22) with normal LVEF, grade I diastolic dysfunction, moderately severe TR Repeat Echocardiogram here showed EF 40-45%, global hypokinesis of left ventricle, moderate AR, mild to moderate MR and TR, trivial pericardial effusion, possibly the drop in EF could be from Afib. Lasix 40 mg IV BID started, transitioned to PO lasix.   Cardiology follows.  Septic shock, resolved In setting of COVID-19, pneumonia Lactate of 6.4 on admission, trended down  Imaging with questionable pneumonia.  Procalcitonin 0.13. Urinary antigens negative.  Blood culture NGTD, sputum culture NGTD. MRSA probe negative. Started on Levophed (1/2/23), weaned off on 1/3. Completed 7 day course with IV Cefepime.    COVID-19 Date of onset of symptoms: 12/25 Symptoms present on admission: weakness, shortness of breath Date of covid positive test: 12/27 at home, 12/30 at hospital Vaccination status: vaccinated with first boosters, did not receive bivalent booster yet Imaging: as below with CXR showing worsening atelectasis vs pneumonia with likely volume overload, repeat CXR with worsening opacities.  Oxygen requirements on admission: room air, but satting 89-90% Current oxygen requirements: ventilator (FiO2 65%, PEEP 10 cm H20). CRP 25.  Medical therapy: dexamethasone course completed, Remdesivir (completed 5 day course) Consultants following: Pulmonology Anticipated special isolation end date: 1/5/23   AKI, resolved Metabolic acidosis, anion gap, resolved Metabolic acidosis likely with her AKI and lactic acidosis Normal renal function at baseline, up to 1.11 from 0.73 with bicarb of 14 on admission. AG of 23 on admission, pure anion gap due to lactic acidosis Cr and bicarb improved.  Monitor renal function with diuresis.    Hyponatremia, resolved Suspect due to poor oral intake, though could have component of SIADH due to viral infection. Sodium of 124 on admission, was 131 at hospital Resolved with diuresis.    Hyperglycemia No prior history of diabetes, last Hgb A1c of 5.5% in 7/21, repeat A1C 5.6. Likely due to COVID.