Please note this patient has a duplicate medical record.  I have asked for admissions to combine these records. Patient is a 76-year-old gentleman with complex past medical history significant a end-stage renal disease on dialysis Tuesday, Thursday, Saturday, COPD on 2-3 liters of home oxygen nasal cannula, heart failure with reduced ejection fraction (45-50%), coronary artery disease, hypertension and diabetes mellitus type 2 who presents to the emergency department via EMS from home for altered mental status. Most history is obtained from the medical record. This patient is known to our services he was previously discharged from this facility on January 18th.  At that time the patient had presented on  At that time the patient had presented on January 6th with altered mental status thought to be secondary to uremia and potentially exacerbated by a new prescription for baclofen in addition to his regular hydrocodone.  His mental status improved with hemodialysis and cessation of alternate agents.  During that hospitalization he also had was believed to be aspiration pneumonia and completed treatment with a course of Zosyn.  He had an elevated 5th generation troponin without anginal symptoms and was started on a heparin drip.  Cardiology evaluated the patient and ultimately felt that his troponins were not related to acute coronary syndrome but rather his end-stage renal disease.  While on a heparin drip his platelets at that time dropped from 194,000 to 37,000 so heparin was discontinued and he was evaluated for HIT.  His heparin antibody test was negative.  He did present at that time with a BNP greater than 70,000 with an acutely reduced ejection fraction of 30 to 35%.  Cardiology added metoprolol to his heart failure medication regimen and his EF improved to 45 to 50% by time of discharge.  The patient was discharged to facility.   The patient is alert and oriented x3 although he is generally a poor historian.  He tells me he returned home from rehab "3 or 4 days ago" and thought he was doing fine.  When I asked him why he ended up in the emergency department he said that his wife called EMS because she was worried about him although he could not elaborate as to what prompted her to think this.  The wife is not present at the bedside, is actually being evaluated in the emergency department herself so is unavailable to help give history.  Nonetheless when EMS arrived the patient was noted to have an oxygen saturation of 73% on room air, with a temperature of 101.9°.  They had a difficult time a getting reliable SpO2 readings while the patient was on 8 liters nasal cannula so they ended up placing him on a non-rebreather mask.  His initial blood pressure was 73/41 so EMS gave patient a 300 milliliters bolus of normal saline.   On arrival to the emergency department the patient remained hypotensive with a systolic blood pressure reading in the 60s.  He was also tachycardic with heart rate above 100 and had a temperature of 100 °.  Blood cultures were obtained and patient was treated with broad-spectrum antibiotics including vancomycin, Levaquin, cefepime.  Patient is anuric so urine culture not obtained.  A right internal jugular central line was placed by the emergency room physician and the patient was started on a norepinephrine drip.  The patient tested positive for COVID-19.  He does state that he completed a COVID-19 vaccine series with a booster but could not elaborate when.  A chest radiograph was performed which showed a right lower lobe infiltrate.  He was taken for a CT of the chest which demonstrated emphysematous changes, bilateral patchy opacities consistent with COVID-19 as well as a moderate left lower lobe pleural effusion.  Other notable findings from his initial evaluation included a white blood cell count of 1,800, hemoglobin 8.1, potassium 5.5, creatinine/BUN 4.2/40, BNP 37000, lactic acid 4.7, procalcitonin 12 and a 5th generation troponin 116.  His initial ABG was apparently performed on room air and was 7.31, pCO2 44, PO2 44, HC03 22.   During time of exam I turned his oxygen down from 8 liters to 4 liters and he was able to maintain an acceptable oxygen saturation for the several minutes I was present.  He does have bilateral rhonchi and is dyspneic with conversation. He is still tachycardic with a heart rate of 105 and had a systolic blood pressure in the 80s while on 8 micrograms/minute of norepinephrine.  He denies having any fever chills at home, denies nausea, vomiting, diarrhea.  Denies sick contacts.  He denies worsening shortness of breath, cough or sputum production.  DISCHARGE:   Admitted 1/30 after wife called EMS about him "not acting right" at home. Had recent admission for CHF and discharged to facility  On admission, was felt to have  sepsis with septic shock, lactic acidosis with hypotension, tachypnea, tachycardia and fever.    He did have positive COVID-19 test but given toxic appearance felt this was more bacterial infection such as bacterial pneumonia, and patient had completed the 3 shot mRNA vaccination series.   Blood cultures obtained,   Started on vancomycin and cefepime, and metronidazole for aspiration pneumonia given history.   Unfortunately, declined quickly, requiring Levophed drip, ventilator support and 100% fIo2  CPR was initiated earlier in the day and Palliative care was of assistance with goals of care with his wife.  He had another bradycardic rhythm into asystole and elected not to revive, he passed comfortably at that time.  He was pronounced at 1725 and I spoke with his wife at bedside shortly after.  Expired at 1725