HOSPITAL ADMISSION SUMMARY; A relatively healthy 51-year-old male who acutely complained of severe pain while he was about to eat dinner with his family at around 4:00 p.m.,  just had 2 bites of carrots when he began having severe abdominal pain described as diffuse and fairly intense. He apparently became diaphoretic and had multiple episodes of vomiting. He profoundly became sick so he was brought to our ER where he initially presented hypoxic and tachypneic. Workups done showed WBC of 17.4, creatinine of 1.36, mild transaminitis and lipase of 40,900. He had undergone CT abdomen which showed findings suggestive of mild pancreatitis centered in the pancreatic head region and an ultrasound which revealed 1.7 cm nonshadowing sessile echogenic nodular focus near the gallbladder which may represent gallbladder polyp versus biliary sludge. He was given 2 L IVF, several doses of fentanyl, Dilaudid and Zofran. Patient was still writhing in pain when I evaluated him. He denies prior history of similar problem and claims he was in his baseline health before the onset of his presenting symptoms. He apparently had a bottle of beer after his routine walk at around 11:00 a.m. to celebrate Memorial day. He is not aware of any hepatic biliary issue and does not drink alcohol regularly (maximum around 6 packs per month). He does have GERD for which he is on PPI. He does not smoke. He is retired from military and currently works for the government. HOSPITAL COURSE- patient presented with intractable abdominal pain and vomiting, found to have acute, mild pancreatitis. Due to lack of improvement a follow up CT of the abdomen was done on 6/4 which showed worsening pancreatic necrosis, developing pseudocyst and superior mesenteric vein thrombosis. On 6/5 he had to be transferred to the ICU for worsening condition. He was eventually intubated and started on dexmedetomidine and furosemide. He remained intubated until 6/8 when he was extubated after he passed spontaneous awakening and spontaneous breathing trial. However his white blood cell continued to climb and remained febrile. At this point vancomycin was started. He was also started on tube feedings. However on the 6/11 he started having significant output from his nasogastric tube. There is question about his ability to absorb medication. After a few days he started showing improvement and general surgery started him on a clear liquid. He continued to improved and he was eventually moved out of ICU to the medical floor on floor on 6/13. However the following day, 6/14, he again had Increased abdominal pain while just on clear liquid diet. A repeat CT abdomen was done which showed increased peripancreatic fluid collection. GI was consulted on 6/15 to evaluate for NJ feeding tube placement. However this was not done until 6/17 due to patient spiking a fever of 101.2 F on 6/16. On his EGD it showed superficial ulceration within the pre-pyloric antrum s/p nasoenteric feeding tube placement. He was again placed on tube feedings. On 6/18 his tube feedings were near goal. However his abdominal pain started to increase again and his abdomen was also noted to be consistently distended. He was also requiring significant amount of IV pain medication. This was discussed with ACS who recommended to get a repeat CT abdomen pelvis. GI also recommended changing his antibiotic to meropenem. Unfortunately he had a reaction to meropenem and after discussion with ID his antibiotic was again changed to Zosyn. His repeat CT in the meantime showed further increase in size and number of pseudocysts. ACS service advised for conservative management and GI discussion. No plan for urgent surgery. IR Service was also consulted to evaluate for cyst drainage but after discussion with ACS they did not go through with the aspiration to avoid fistula formation. At this point the patient was taken of tube feeding and was placed on TPN. The patient finally started having consistent improvement. His WBC trending down and became normal. His NGT was eventually discontinued as well as his antibiotic per GI and ACS recommendation on 6/23. He had a repeat CT abdomen and pelvis on 7/6 which showed no definite pancreatic necrosis and pseudocysts remain unchanged. His nausea managed eventually with scheduled reglan and PRN zofran and for his pain, PRN dilaudid and scheduled ER oxycodone. He is tolerating his TPN and oral meds with sips of water at this point but still couldn't tolerating any food orally. The patient will need to have another CT abdomen and pelvis done with contrast to evaluate the pseudocyst in 4-5 weeks (end of July). He can then be referred to outpatient GI through the VA to determine if he needs aspiration of his pancreatic pseudocyst. This was the recommendation by ACS and GI here in the hospital. FINAL DIAGNOSIS- Acute pancreatitis necrotizing/ Pancreatic pseudocyst secondary to above/  Severe sepsis/ Orthostatic hypotension/ A. Fib/ Mesentric vein thrombosis partial/Acute respiratory failure with hypoxia/ MRSA pneumonia/ Transaminitis/ Ileus: resolved/ Encephalopathy/ Elevated blood sugar:/ Protein-calorie malnutrition, moderate/ Drug rash