Patient is a 75 y.o. female with a history of seronegative myasthenia gravis, tracheostomy dependence, atrial fibrillation (on Xarelto), HFrecEF, hereditary and idiopathic peripheral neuropathy who presented to Hospital 9/29/23 with dyspnea. Transferred to another hospital ICU 9/29/2023 for respiratory failure, atrial fibrillation with RVR, and COVID -19 infection. Transferred out of ICU 10/3/23. Hospital course complicated by further worsening of respiratory status with blown trach requiring transfer back to ICU and upsizing of trach and bronch 10/5/23. Hospital reassumed care 10/11/23   1. Acute on chronic hypoxic hypercapnic respiratory failure: Baseline trachmask and  BIPAP 12/6 HS with trach uncapped (pt reports feeling SOB when BIPAP is capped), s/p tracheostomy due to MG/OSA on 6/28/2023. .Acute worsening likely secondary to COVID 19 infection, possible HAP. Worsening respiratory status again 10/4/23, with blown cuff with #4 trach, s/p upsizing to #6 cuffed trach 10/5/23. Weaned back to TM during day and Vent HS.  Pt was trialed on BIPAP HS however was constantly alarming uncapped.  Trialed capped and patient was unable to tolerate due to our face make.  Per pulm ok to resume home BIPAP uncapped at facility per her home setting 2. COVID infection: COVID positive 9/29/2023 - exposed at her ECF. Completed 5 day course Remdesivir 10/3/23 and 10 day course Decadron 10/8/23. Isolation duration per infection control  3. Concern for HAP: with worsening respiratory status 10/4/23. CXR 10/5/23 with slightly improved nonspecific perihilar and lower lung opacities compatible with edema vs pneumonia. MRSA swab 10/5/23 negative. S/p bronch with BAL 10/5/23; culture negative. Vanc stopped 10/5/23. 5 day course Cefepime stopped 10/8/23.  4. Shock: suspect due to sedation while on ventilator. Initial concern for sepsis on admission, however blood and urine cultures negative. S/p empiric abx as above. Weaned off pressors.  5. Acute metabolic Encephalopathy: suspect secondary to infection, sedation, ICU delirium. Improved. Supportive care, delirium prevention measures.  Improved 6. Afib with RVR: per history, s/p ablation in 2018. CHA2DS2-VASc score 6. Home Xarelto held on admission and placed on heparin drip, transitioned back to DOAC 10/1/23. BB held due to sepsis. Monitor.  7. Chronic HFrecEF: per history, follows with cardiology. TTE 10/2/23 with EF 55-60% mild enlargement of RV with normal function. Admit BNP 2186, monitor volume status 8. SSS: s/p pacer 2019 9. Chronic Dysphagia: in setting of trach. SLP recommended regular solids/nectar thick liquids; PMV must be on all with all PO intake, must cough to clear after all sips/bites.     10. Myasthenia Gravis with immunosuppression: since 5/2022, history of myasthenia gravis crisis requiring IVIG in the past. Follows with Neurology. Continued home pyridostigmine and prednisone, Bactrim for prophylaxis. Avoid medications that can cause MF flare: flouroquinolone, aminoglycoside, Macrolides beta blockers, botox, muscle relaxants, lithium, magnesium.   11. Restless leg syndrome: Continued Requip 12. Morbid Obesity: Body mass index 43.03 kg/m² on arrival.  13. OSA.OHS: baseline BIPAP mask 12/6 HS with trach uncapped,  14. Code status: Palliative confirmed DNR-Cca but ok with ventilatory support on 10/11/23