Patient is a 66 y.o. female who presented from ECF on 9/9/2023 with increased dyspnea and lethargy - found to have marked hypercapnia requiring persistent BiPap in the ED.  History significant for COVID-19 Dx ~4 days PTA.     Acute on Chronic Hypercapnic and Hypoxic Respiratory Failure Respiratory Acidosis Acute Exacerbation of COPD - With significant COPD history, likely exacerbated by sedating medications and COVID-19 infection. - Presentation VBG pH 7.20, pCO2 undetectably high (~120).   - Initially required Bipap for hypercapnia - Currently weaned down to 4L NC (3L NC at baseline) - pt was started in BIPAP on admission  - respiratory status improving, ABG's improved; pH normalized and pt taken off bipap - Continuing triple inhaler therapy.  Unable to give Duo-nebs due to hospital policy with COVID - cont azithromycin. - Continuing steroid therapy for COPD and COVID as below.   COVID-19 - Presented with: hypoxia, hypercapnia - Symptom onset: on 9/5 (approximately 5 days PTA) - Positive COVID-19: 9/6 at ECF and positive here on admission 9/10.  - Vaccination status: Unknown - CXR showed no evidence of airspace consolidation. - Oxygen status: on BiPap on admission; now down to 3-4 L NC - Decadron: Yes. Expected end date 9/19 - Remdesivir: yes, end date 9/12 - DVT prophylaxis:Lovenox - Serial COVID labs ordered: No   Acute Metabolic Encephalopathy Dementia  - acute component due to hypercapnia above. Also some contribution possible from benzo/opiate use and acute infectious process. - pt with underlying dementia; per pt's brother pt with some baseline confusion though seems she is currently not at her baseline - awake and alert though disoriented on exam; follows commands; right sided upper ext weakness noted and chronic - given recent falls at ECF, will obtain CT head to ensure no acute bleed  - pt's home scheduled ativan, gabapentin and prn morphine held on admission due to mentation  - today pt now awake and alert though disoriented; follows commands - called ECF and confirmed pt on 1 mg ativan scheduled tid  - will resume ativan at low dose 0.5 mg tid here and restart gabapentin lower dose at 100 mg tid  - will hold prn morphine still    Hx of Opiate Use Disorder with Chronic Opiate Dependence Suspected Benzodiazepine Dependence - Complex history, previously on Methadone on last discharge from OH (7/2022).  ECF med list with Suboxone TID, Morphine PRN, and Lorazepam tid scheduled  - Continue suboxone; adding back half home dose ativan tid - holding prn morphine    Major Depressive Disorder - Continue home Buspar 20mg TID and Prozac 30mg daily.   Dementia - Per history. - Continue home Aricept.   Thrombocytopenia - Acute, suspected in the setting of acute viral infection as above. - PLT 106 on admission and down to 90 today  - B12 normal; iron studies low with normal ferritin  - monitor    Hx of Hypertension Hx of DM2 - Previously on Amlodipine and Metformin, but since discontinued.  Suspect in the setting of possible Hospice admission. - hgbA1c 5.1% - Continue to monitor BPs   Hx of CVA - With noted RUE weakness chronically. - Continue home ASA 81mg.   Hx of Hepatitis C - Unclear treatment history. LFTs within normal limits on admission. - Continue OP follow-up