CASE PRESENTATION: An 82 year old Caucasian female presented to the hospital with complaints of worsening shortness of breath at rest for 7 days. She has had similar episodes of shortness of breath since 2007 which were diagnosed to be COPD exacerbations. Her past medical history was significant for systolic heart failure, COPD, hypothyroidism, deep venous thrombosis, hypertension, and CKD. Patient is a lifelong nonsmoker. Her home meds included levothyroxine, valsartan,furosemide, rivaroxaban, tiotropium, fluticasone-salmeterol, carvedilol. Her HR was 124 beats/min, SpO2 99% on 2 liters, RR 20, trace pedal edema and bilateral rales.Her WBC was 15,400/mm3, Hb 8.3 g/dl, Creatinine 1.36 mg/dl, BNP >5000pg/ml. EKG showed sinus tachycardia. Chest ray showed decreased right-sided lung volume.Transthoracic echocardiogram showed LVH and mild systolic dysfunction. CT angiogram of lung showed no evidence of pulmonary embolus in the left pulmonary artery, no visualized right pulmonary artery with extensive cystic changes were noted in right hemithorax predominantly peripheral,with increased adjacent atelectasis and right hemithorax volume loss. For her acute on chronic exacerbation of her congestive heart failure patient was treated with carvedilol and furosemide. The patient was also given steroids and levofloxacin for COPD exacerbation. She was discharged on day six maintaining the bronchodilator and heart failure therapeutics.