Provider Summary: ""Patient is a 59 year old female with history of COPD, HTN, HLD, CAD, MI, chronic pancreatitis, tobacco use and alcohol abuse presenting with two days of worsening lower extremity swelling and pain as well as head and lumbar back pain after sustaining a fall in her bathtub. Patient admitted to taking 8-500 mg extra-strength tylenol daily with 3-4 ""generic over-the-counter tylenol"" of unknown strength daily with norco daily. She was tachycardic on presentation, otherwise her vitals were stable. She was a cachectic, elderly appearing female with bilateral pitting edema to the knees and some generalized weakness on physical exam. Labs demonstrated a bicytopenia with a hemoglobin of 10.4 and a thrombocytopenia of 69,000. Additionally she had a BNP of 2,447, an elevated venous lactate of 8 (fluid bolus and vancopmycin ordered as patient was meeting sepsis criteria) and a procalcitonin of 16.69. Her D-dimer was elevated to 1,730 (CT chest ordered). She was hypokalemic to 2.2 (K replaced), with elevated AST of 1,927 and ALT of 328 with a total bilirubin of 6.0. Acetaminophen level was 38.8. A hepatitis panel was negative. INR was 6.4. GI was consulted and she was administered NAC for acetaminophen-induced acute hepatitis. She was placed on CIWA protocol and thiamine and folate were ordered. Pancreatic enzyme replacement ordered for pancreatic insufficiency. Fluids for lactic acidosis.   Ultrasound of the bilateral lower extremities was negative for DVTs. CT of the chest demonstrated subsegmental pulmonary embolism with right heart strain and bronchitis. She was started on a heparin gtt. Chest x-ray demonstrated no acute cardiopulmonary process. ECG showed sinus tachycardia with low voltage QRS and non-specific T-wave changes in the inferior and anterior leads. Right upper quadrant ultrasound demonstrated possible medical liver disease with abnormal gallbladder findings. Abdominal X-ray showed evidence of chronic pancreatitis without evidence of mechanical obstruction. ECHO demonstrated an EF of ~50%, some mild LVH, mild left ventricular dysfunction, basilar hypokinesis, mild MR, and no evidence of intracardiac thrombus or pericardial effusion. HIDA scan demonstrated a patent cystic duct without cholecystitis. CTA abdomen pelvis demonstrated diffuse wall thickening of the colon and stomach with moderate ascites, small bilateral pleural effusions and anasarca.    On 6/3 the patient was admitted to the ICU. She had some frank blood per rectum. Imaging as discussed above. Platelet count decreased and INR worsened. Heparin drip was discontinued and she was administered cryoprecipitate. She was started on Zosyn for potential colitis. Fluids were switched to bicarb gtt. Consideration for transfer to tertiary liver center. Patient was accepted to Facility for transfer pending bed availability. Patient experienced acute respiratory failure and was placed on BiPAP. She was started on Rifaximin and Lactulose. Her INR began to improve. She was having difficulty with urination, urology was consulted and a foley catheter was placed. Patient became increasingly encephalopathic. She was started on diuretics as her pitting edema extended to the thighs. Attempt to transfer patient to Facility was declined as patient was improving and bed was not yet available at Facility. She was taken off of BiPAP. Lactic acidosis improved. She had no additional episodes of blood per rectum. Repeat CT demonstrated stable PE. On 6/5 she was transferred out of the CCU and Zosyn was discontinued.   6/6 Patient admitted to some visual hallucinations but was A&Ox3 (stage II Hepatic Encephalopathy per GI). Lactulose was titrated to meet goal bowel movements. Her INR and LFTs gradually improved. As there was continued improvement in patient's encephalopathy and coagulopathy attempt at transfer was put on hold. Patient continued to be mildly encephalopathic. Patient had poor oral intake and diet was supplemented with Ensure. On 6/10 her hgb was 7.0 but she was asymptomatic without signs of overt bleed. She was started on diuretics.  As patient was less encephalopathic voiding trial was attempted per urology recommendations. Patient was able to urinate on her own with some continued retention. Accuracy of bladder scans was compromised by ascites.     On the morning of 6/13 patient experienced three episodes of brownish-red emesis, shortness of breath and abdominal pain. Her hemoglobin dropped to 6.8. GI planned for upper GI scope so patient was transfused 1 unit RBCS and 2 units platelets and placed on protonix. Scope revealed esophageal erosion vs shallow ulceration in distal esophagus, a widely patent, non-obstructing and mild Schatzki ring, a medium-sized hiatal hernia, gastric erosions, and duodenitis. H. Pylori stool antigen was negative. Patient also started on albumin challenge as lower extremity edema showed little improvement.       On 6/15 bedside ultrasound-guided paracentesis was performed yielding 10 cc of clear straw-colored fluid.  Analysis revealed transudate with no growth of organisms on cx. On 6/17 that patient's hgb dropped to 6.8. She was administered a unit of RBCs. During the transfusion she anxious and ox sat dropped to 84 on 2L. NC was titrated up to 3L. On 6/17 the patient tested positive for COVID. Given liver and kidney function patient was not a candidate for Remdesivir or Decadron. Oxygen requires continued to increase. IRN began to worsen. She went into Afib with RVR. She was hypoglycemic and tachycardic to 200. D50 was administered. IV metoprolol administered. Vitals stabilized. Patient had continued complaint of chest pain. CT pulm redemonstrated PE, with moderate worsening pleural effusions, worsening atelectasis/infilitrate lower lobs, complete atelectasis of right middle lobe, with worsening edema within the mediastinum and neck base. Bilateral lower extremity venous ultrasound showed no dvts. Patient was transferred to PCU. On 6/18 patient had additional episode of Afib with RVR. Rate was controlled. On the morning of 6/19 patient was hypoglycemic to 27 and tachycadic. Amp of D50 was administered as well as IV metoprolol and small IV bolus. Vitals stabilized. Patient was more lethargic. By the evening patient had produced almost no urine. Renal ultrasound did not demonstrate hydronephrosis or other acute renal pathology. Patient also had swelling of the right upper extremity. US of the extremity did not show DVT. CT of the head did not demonstrate acute intracranial abnormalities. Her kidney function worsened. Family requested that we attempt to transfer patient to tertiary center again. Patient was accepted to Facility but a bed was not available. Patient decompensated overnight. Her blood pressure dropped. She was not following commands. Her heart rate dropped into the 30's. Patient's family requested comfort care measures, code status updated to DNR/DNI. Patient given fentanyl, ativan and scopolamine patch and placed on BiPAP.  Family was at bedside as patient passed away at 3:50AM on 6/21/22."