Patient is a 70 y.o. female patient with history of CAD, HFpEF, CKD, COPD, dementia, GERD, HTN, OSA, seizure and obesity who presented with dyspnea, found to have pleural effusions and COVID+   Goals of care Given rapid decompensation, multiple co-morbidities and changes in mental status, family elected for comfort care and compassionate extubation Pt. Passed away 2/24 @ 1519   Acute on Chronic Hypoxemic Respiratory Failure Bilateral pleural Effusions Multifactorial, including volume overload, COVID, anxiety, COPD Requiring 4L NC on admission  Baseline O2 requirement: 2L CT w/large bilateral pleural effusions w/compressive atelectasis VIR consulted for thoracentesis - removed 1L 2/13, transudate Was on IV diuresis (held for AKI) CXR 2/19: Multifocal airspace opacities improved on right and stable on left Decompensated 2/20 requiring intubation  Compassionate extubation 2/24   Leukocytosis WBC 9k (2/12) > 22k (9/23) No clear source was identified and had no change in steroids for COVID CXR with decreased pleural effusion and mild right basilar consolidation CXR 2/19 as above MRSA probe positive On Vanco/cefepime (2/19) Now WBC increased from 22k (2/22) > 45K (2/23) BCX (2/23) NGTD at the time of discharge, Sputum Cx pending ID followed Possible Cholecystitis Given rising WBC count, ordered CT C/A/P CT C/A/P with cholelithiasis with gallbladder hydrops concerning for possible acute Coley US abdomen with sludge in gallbladder with mild distention HIDA scan negative for acute cholecystitis Antibiotics changed from cefepime to Zosyn Surgery followed and does not think cholecystitis   COVID-19 Symptom onset unclear in setting of CHF exacerbation Test positive 2/10 Mild GGO present on CT chest, may be largely pulm edema Given dexamethasone course and remdesivir 2/10  stopped remdesivir after 2/11 due to decreased CrCl Out of isolation 2/20   Acute on Chronic HFpEF Presented with volume overload and b/l pleural effusions Looks like diuretic not included on her discharge med list 2/6, cardiology had recommended torsemide 20mg BID and renal had recommended no diuretic until outpatient follow up Per CHF RN note, no issue with intended compliance but multiple barriers including no insurance, no transportation BNP 11k, baseline ~11-12k ECHO 8/2022: EF 67%, grade 2 diastolic dysfxn Given IV Lasix in ED, held briefly for rising Cr as above Strict in/outs, daily weights Net IO Since Admission: -10,326.87 mL [03/02/23 1532]   AKI on CKD Stage IIIa Suspect pre-renal 2/2 diuresis vs secondary to CRS Recent admission w/AKI, Cr peak 2.07 Creatinine around 1.4 on admission, up to 2.0 with diuresis; hold lasix for now, resume diuretic when able Home ARB previously stopped Strict in/outs, monitor UOP Generalized Anxiety Disorder Symptomatic, uncontrolled Largely driving respiratory distress on admission As needed Atarax ordered BH consult: continue buspirone, mirtazapine, and duloxetine at home dosing   Acute Metabolic Encephalopathy Multifactorial, including hypoxia, hypercarbia, polypharmacy, infection Fluctuating status since admission, presents as delirium No focal neuro deficits on exam UDS, UA, TSH, Ammonia, B12/Folate unrevealing Limit sedating medications as able Delirium precautions Was resolved prior to intubation Concern for not following commands while sedated CT Head STAT 2/22 w/o acute process.  LTM EEG 2/23 with severe encephalopathy, generalized and L hemispheric sharp activity suggesting increased risk for seizure but no active seizure noted Neuro followed and ordered MRI brain and family refused as planned for compassionate extubation COPD, w/o acute exacerbation No wheeze, presentation primarily due to CHF + COVID Resume home controller therapy Aggressive pulmonary hygiene PRN Nebs   T2DM, insulin dependent A1c 7.3 but anemic Home Lantus 25U at bedtime Titrating Lantus up to 30u BID   Anemia of Chronic Disease Stable, w/o active bleeding Hgb 8-9, baseline 8-9 Iron studies 1/31 AoCD pattern Monitor,  transfuse <7   Persistent atrial fibrillation Chronic, borderline tachycardic Continue home diltiazem Added metoprolol 25mg BID, rates trended down to <60 on this, stopped 2/14 Eliquis held for procedure, resumed thereafter   OSA/OHS Chronic, controlled CPAP when weaned off of vent   Sacral Decubitus Ulcer, POA Secondary to immobility Wound care consulted