Hematologist/Oncologist: MD  Primary Care Physician at Discharge:      PRESENTING PROBLEM: Encephalopathy acute    HOSPITAL COURSE: The patient is a very pleasant 58-year-old male with past medical history as listed above including pancreatic cancer, who presented to Emergency Department secondary to generalized fatigue, severe lower extremity edema and intermittent confusion.  Initial laboratory studies and imaging can be found per Epic review.  His encephalopathy was felt multifactorial secondary to toxic metabolic encephalopathy, AKI with electrolyte derangements, infections, and medications.  COVID-19 was positive on presentation.  Cycle threshold was 34.2.  The patient was asymptomatic and not hypoxic.  ID was consulted.  No indication for treatment.  Chest x-ray showed atelectasis and small bilateral pleural effusions.  He underwent a CT chest, abdomen, and pelvis on presentation that showed progression including new air bubbles within the pancreatic lesion possibly reflecting necrosis or fistula formation with bowel most likely duodenum, superinfection of tumor cavity was also possible.  Surgical Oncology and Gastroenterology were consulted.  Surgical Oncology evaluated the patient, felt a small amount of gas within the pancreas most likely due to tumor necrosis and no surgical intervention offered regardless of the etiology of this foci of pancreatic air.  GI felt the fistulization was likely due to tumor and could repeat imaging of worsening clinical status.  The patient had increasing ascites on CT scan and underwent a paracentesis on September 19.  Later, peritoneal drain was placed per IR.  Gastritis was noted on CT and the patient was placed on a PPI 2 times a day.  Nephrology was consulted for AKI and hyperkalemia.  They felt this was likely due to prerenal azotemia and likely ATN in the setting of hemodynamic changes from sepsis and COVID-19 infection and likely would be further evolution of AKI due to contrast induced nephropathy with IV contrast dye administered on September 16th.  There was no obstruction or hydronephrosis.  He was given Lokelma, but this was ineffective.  He was placed on a bicarb drip.  He was started on IV albumin and this was continued until discharge.  Given the grave prognosis of his metastatic pancreatic adenocarcinoma, CCRT would not improve his situation.  Quality of life would most likely be worsened by it.  Bilirubin was elevated throughout the hospital stay.  CT did show stent in place.  He had a coagulopathy and received vitamin K and FFP.  He was placed on a heparin drip for a new portal vein and superior mesenteric vein thrombus as well as splenic infarct, however, this was discontinued with coagulopathy and increased risk for bleeding.  Home Eliquis was also held.  Palliative Care was consulted to assist with abdominal pain and cancer related pain.  Overall, given progression of disease seen on imaging, hospice was recommended.  Several goals of care, conversations we had had with the patient and the family and initially family wanted all aggressive treatment until his body gives up completely.  On 09/19, further lengthy goals of care resulted in patient and family wishing to pursue hospice given the grave nature of his disease and he will be discharged home today 09/25/2022 in stable condition with plan to sign on with hospice at home.