Patient is a 71 y.o. female with a past medical history of pancreatic adenocarcinoma, NASH cirrhosis, CKD, HFpEF, HTN, GERD, esophagitis.  She who presented on 9/29/2023 with fatigue and weakness. She was found to have C difficile colitis and was treated with IV metronidazole and oral vancomycin. Hospital course complicated by decompensated cirrhosis, failure to thrive, and flash pulmonary edema with respiratory failure and transfer to MICU 10/8/23 for airway monitoring. After discussion with patient's spouse, code status changed to DNRCCA/DNI per her previous wishes. Course further complicated by COVID pneumonia; she was started on decadron and remdesivir. She remained dependent on BIPAP and HHFNC. Ongoing goals of care continued with Palliative team. After further discussion, family decided to transition to comfort care on 10/12/2023. She passed away with family at bedside at 1749 on 10/12/2023.    Discharge Diagnoses:   Acute Respiratory Failure with hypoxia Secondary to Pulmonary edema and failure to thrive - CXR 10/8: with diffuse pulmonary alveolar infiltrates, concerning for ARDS - Transitioned between BIPAP and HHFNC, goal SpO2: 88-92% - Continued diuresis for dry lung strategy  - DNRCCA/ DNI, Palliative consulted given critical illness - Ongoing goals of care continued with Palliative team. After further discussion, family decided to transition to comfort care on 10/12/2023.    COVID-19 - Respiratory PCR positive for COVID 10/9.  - Initiated Remdesivir, Decadron 10/9 - Continued isolation    C difficile Colitis Typhlitis Pancolitis Sepsis Per culture data 9/30/23 - CTAP 9/29/23 with pancolitis - Repeat CTAP 10/5/23 with worsening inflammation, ceftriaxone added to antibiotic regimen 10/5 - Ceftriaxone discontinued 10/9 per ID recommendation - Surgical Oncology previously followed, signed off 10/8, will only consider surgical intervention if perforates due to high risk for morta- - -Started on IV metronidazole and oral vancomycin 9/30, regimen completed 10/11 Decompensated NASH Cirrhosis Hepatic Encephalopathy Transaminitis Per history - EGD 5/1/23 with esophageal dilation, gastritis/esophagitis/duodenitis, no EV - EGD 5/19/23 with small EV, no banding - MRI liver 5/11/23 with cirrhotic liver with small ascites, pancreatic cysts - CTAP 10/5 with worsening ascites - Liver US 10/8 showed cirrhotic liver with moderate ascites as well as a 19mm cyst; normal hepatopetal flow.  - MELD score 20 - Diuresis as above  - Continued HE prophylaxis with rifaximin, lactulose held given C difficile - No more than 2 grams of Tylenol per 24/hours - Midodrine 10mg TID 10/9 to augment renal perfusion   Acute on Chronic diastolic heart failure  Pulmonary Hypertension, Suspect Type II Per history - home regimen includes furosemide - TTE 5/2023 with LVEF 65%  - TTE 10/9/23 shows LVEF 69%, pulmonary HTN with an estimated right ventricle systolic pressure 41mmHg - continue diuresis as above - maintained normotension, optimized electrolytes and fluid status    Severe Protein Calorie Malnutrition Failure to Thrive Electrolyte Dyscrasias - Tube feeding recommendations for Peptamen 1.5 at @20mL/hr with slow advancement to goal rate of 50mls/hr - Initiated Thiamine supplementation for refeeding risk, electrolytes q6h - TF started 10/9, continued at goal    Hyperglycemia 2/2 steriods for covid -Insulin gtt continued  Hypernatremia, improving Likely due to poor po intake and diuresis -Serum sodium 145 -spot diuresis -Free water continued     Lactic Acidosis Secondary to C difficile colitis and hypoxia - Lactate improved initially with fluid resuscitation - Lactate elevated, stable   Pancreatic Adenocarcinoma Pancreatic Pseudocyst Of pancreatic tail, diagnosed in May 2023, status post distal pancreatectomy/splenectomy with drain placement on 6/22/23 with Dr. - Active chemotherapy treatment prior to admission with gemcitabine/xeloda, began 9/6 - Most recent chemotherapy treatment was 9/29 - Received neupogen 9/30 with initial increase in counts - Surg Onc recommended against further chemotherapy given inability to tolerate and previous hospitalization   Hypokalemia, resolved - Likely secondary to diuresis with Lasix - Potassium back up to 3.9 on 10/9   Thrombocytopenia, resolved Secondary to chemotherapy and chronic illness - Daily CBC - No signs of active bleeding - Transfuse for platelets <10 - SRA and PF4 negative, change fondaparinux to enoxaparin   Neutropenic Fevers, resolved - 2/2 C. Diff colitis - Daily CBC