Discharge Provider:  Primary Care Physician at Discharge: MD  Admission Date: 8/28/2022  PRESENTING PROBLEM: Shock (HCC) [R57.9] MSSA bacteremia [R78.81, B95.61]   HOSPITAL COURSE: 62 y.o.male with past medical history of severe aortic stenosis, provoked DVT (2018) not on current anticoagulation, right retinal branch occlusion (03/2022), carotid dissection, and alcohol use disorder who presented after a ground level fall at home.  EMS was called to the home and noticed possible right sided facial droop and slurred speech without extremity deficits. On arrival to the emergency department, the patient was hypotensive, tachycardic, and febrile. Code stroke was called and CT head, CT perfusion, and CT angio were negative for acute stroke. An additional finding on imaging was mild T1-T3 superior endplate compression fractures. Lab work was notable for hyponatremia (126), AKI, lactic acidosis, leukocytosis, elevated troponin, and Covid +. Sepsis protocol was initiated with the patient receiving 4L IVF, but ultimately necessitating pressor support. EKG also revealed new T wave inversions and T wave depressions in V1-V6. Heparin gtt was initiated due to concern for NSTEMI. The patient was transferred to MICU for further care. Further workup included blood cultures (positive for MSSA), CT abdomen/pelvis (scattered pulmonary nodules; lesion in segment 6 of the liver; marked enlargement of the right ureter and large right ureterocele), RUQ US (lesion in segment 6 revealed to be hemangioma), stool studies (negative), TTE (without wall motion abnormalities, LVEF preserved), and MRI brain (several scattered foci of restricted diffusion involving bilateral occipital lobes, inferior left cerebellum, and superior right cerebellar hemisphere). The constellation of symptoms and findings is suspicious for infectious endocarditis. Cardiology consulted. Infectious disease consulted. Patient was started on ancef for infective endocarditis.     Hospital course further complicated by GIB with hemoglobin drop. GI consulted - patient underwent EGD that showed duodenal ulceration with visible vessel spontaneously oozing status post epinephrine injection into clipped with hemostasis achieved.  The next day the patient started having bloody bowel movements  and blood clots. Another EGD did not show any acute findings.  Additionally, patient underwent Flex sigmoidoscopy which revealed No heme in rectal vault and a Large prolapsing hemorrhoids. Colorectal surgery consulted and managed conservatively. Additionally, the patient started having hematuria therefore a Foley catheter was placed and intermittent irrigation was applied with flushes. Patient developed worsening vitals and chills, CTAP and HIDA revealed concerns for cholecystitis. Antibitoics changes to cefepime and flagyl and IR and surgery consulted. 9/7, patient developed type 2 heart block with further progression to episodes of complete heart block. Patient underwent TEE which revealed concerns for aotic valve abscess. Ultimately on 9/9 patient developed v fib arrest, code blue was called and were unable to achieve ROSC despite multiple rounds of CPR and epi. Patient ultimately expired 9/9/2022 @ 13:05pm. Wife and daughter at bedside during code.