64-year-old male with heavy prior smoking history and COPD as well as alcohol dependence, presented with hypothermia after being found out on the lake clean into a kayak.  Blood alcohol levels were elevated on intake.  He was intubated for respiratory protection and presumed lake water was reported to be aspirated to a moderate amount from the lungs.  He was admitted to the ICU.  He was treated with rewarming protocols, and empiric IV antibiotic coverage and steroids for aspiration pneumonitis and possible early pneumonia.  He slowly improved with treatments and was able to be extubated couple days after admission, with further subsequent improvements and decrease of oxygen requirements.  He completed 7-day course of empiric IV Rocephin for possible aspiration pneumonia.  Due to slow improvement, COVID test was checked several days after admission, and was positive.  He was started on remdesivir and steroids changed to Decadron, however after further discussion and being aware that his family was reportedly all positive for COVID the past 1 to 2 weeks, though he had no testing at that time, it is presumed that his COVID positivity is not likely acute and just an ongoing residual from previous likely asymptomatic infection.  COVID was not checked on intake given circumstances of presentation being intoxicated and found with overt nonsterile water aspiration.    Today, patient is further improved and down to minimal oxygen.  Still has increased oxygen demands with any ambulation and home O2 eval completed and qualifying him for oxygen at home.  We will continue steroid wean after discharge however no additional antibiotics as complete course was finished here in house.  Advised to follow-up with PCP and request pulmonology referral as well as PFTs when he is improved back to his baseline.  He does state that prior to all these events occurring, he noted that home O2 sats do drop into the low to mid 80s on room air at baseline.  Pulmonology was consulted this admission and reviewed imaging suggest that his baseline COPD is severe.  He does still smoke a couple cigarettes a day and he was advised to work towards complete cessation.  He was covered with CIWA protocols during this admission given intoxication and chronic alcohol dependence but had no complications from withdrawal.  He is stable for discharge today with home health services.   Assessment and Plan Patient is a 64 y.o. male patient of DO with history of smoker, alcohol abuse presented to the local Hospital with hypothermia.   Acute respiratory failure hypoxia and hypercapnia Septic shock, resolved Lactic acidosis, resolved Patient pulled from Lake clinging to kayak Extubated 2/27 Recurrent fever <24hrs, source likely aspiration pneumonitis versus pneumonia Chest imaging without evidence of acute pathology Blood cultures NGTD Pulmonology consulted Cont IV Rocephin empirically, completed full course during stay, no abx on DC Continues minimal O2 at rest, requiring 3 L nasal cannula with ambulation Current leukocytosis likely secondary to steroids New COVID-19 positivity versus prior residual ongoing positivity Reportedly family members tested positive the week prior to admission but patient never tested himself He is fully vaccinated and booster x1 On intake, COVID was not checked due to situation of his presentation COVID test 3/1 positive Higher suspicion that his positive testing is residual rather than new infection, pulmonology agrees DC remdesivir Continue decadron taper on discharge   COPD in exacerbation Likely aspiration pneumonitis Possbile aspiration pneumonia Stridor s/p extubation Pulmonology following Steroids taper on discharge Cont Symbicort Wean O2 as tolerated to goal 88-92% Will DC with home O2 3L for ambulation   Hypothermia, resolved Secondary to cold water exposure Admission temperature 85.6, now normalized   Metabolic encephalopathy, resolved Secondary to severe hypothermia Combined with alcohol abuse/intoxication Was agitated in ED, requiring sedation and intubation Resolved and extubated   Alcohol abuse/alcohol intoxication Continue on folic/thiamine on DC SW consulted for etoh cessation resources   CAD Atelectatic changes in the CTA chest from 8/2019 Prior nuclear test from 10/2019 with possible prior infarct Continue ASA/statin