Discharge Provider: DO Primary Care Provider: NP Admission Date: 9/18/2022 Discharge Date: 10/03/2022  PRESENTING PROBLEM: Acute renal failure (ARF) (HCC)  AKI (acute kidney injury) (HCC)    HOSPITAL COURSE: Patient is a 70 year old male with hx of HTN, thoraco-abdominal aortic aneurysm sp TEVAR (Jan 2022), CKDIIIa, OSA, chronic gastritis, protein calorie malnutrition and deconditioning who presented with 1 week of generalized weakness and was admitted for urosepsis, AKI, and COVID-19. He was lethargic and slow to answer questions on admission and oriented only to location. He was found to have a UTI from Klebsiella as well as acute hypoxic respiratory failure likely from COVID. He was treated Decadron for 10 days for his COVID. Upper and lower extremity US's were obtained which showed extensive DVT within his right lower extremity from femoral vein through posterior tibial vein. He was then started on a heparin drip. His encephalopathy was suspected from delirium with components of his sepsis and COVID. MRI brain was ordered which ruled-out stroke. He continued to have encephaloapthy despite antibiotics and so thiamine was ordered to empirically treat for Wernicke's. Something was placed for severe protein calorie malnutrition with inability to meet nutrition goals through oral intake. While he was on heparin drip, he then had an acute drop in hemoglobin. Heparin was held. No blood transfusions were given. GI was consulted as he does have a history of peptic ulcer disease with EGD in July 2022 which showed multiple benign-appearing ulcers in the antrum. He also started having black bowel movements as well. He was started on IV PPI drip per GI and he was deemed high risk for anesthesia with endoscopy with a hemoglobin <7. Interventional radiology was consulted for placement of IVC filter as his acute DVT was untreated. They did not recommend an IVC filter to be placed with his hemoglobin continuing to be around 5. IR was also asked about possible embolization for his upper GI bleed, but CTA was needed prior. Unfortunately, he had poor renal function. He had AKI on CKDIIIa likely due to ATN from his urosepsis and poor oral intake. His renal function continued to be poor and he developed hyperkalemia that was responsive to treatment. Since 9/26 His dark, tarry bowel movements ceased and hemoglobin remained around 4-5. Bloodless management of severe anemia recommendations were given which included high doses of Vitamin D3, EPO, IV iron, Folate, and Vitamin B12 as well as 6L of oxygen through nasal cannula. As no intervention was able to be done for his DVT and his hemoglobin was stable with no signs of active bleeding his case was discussed with UofM who agreed to transfer.   Of note, on 9/30 patient did develop a new painless mass on the right inner thigh. An US was done and show an avascular lesion concerning for possible abscess or hematoma. Given lack of pain or purulent discharge hematoma was considered and this could be affecting patients hemoglobin.    Patient's family was regularly updated with goals of care conference and Palliative Care consult was offered. Patient's wife who is DPOA declined Palliative Care consult at that time.   -- On 10/1, patient had acute blood loss anemia from left calf hematoma. Hb 4s. Unable to receive blood and transferred emergently to U of M.