Discharge Physician:  MD; Primary Care Physician: MD; Date of Admission: 1/8/2023; Discharge Date: 3/15/2023 Room Number: PRESENTING PROBLEM: Acute hypoxemic respiratory failure (HCC) [J96.01] Tracheoesophageal fistula, acquired (HCC) [J86.0] Esophageal cancer (HCC) [C15.9] Acute on chronic respiratory failure (HCC) [J96.20] Septic shock (HCC) [A41.9, R65.21] 56-year-old with a PMH of non-Hodgkin's lymphoma s/p chemotherapy and radiation 1992, hx of left bundle-branch block and complete heart block s/p pacemaker, hypertension, severe GERD, HFPEF, and squamous cell esophageal cancer s/p esophagectomy 8 months ago, stent placement 6 months ago and hospitalizations x4 for recurrent pleural effusions, pneumonia, hypoxia, and aspiration who presented to the ER 1/7/23 with shortness of breath. Patient was found to have moderate to large bilateral pleural effusions with adjacent compressive atelectasis vs pneumonia. Patient was started on azithromycin and Rocephin and was transferred to Hospital for admission. Pulmonary was consulted and recommended cont pleurX drain.  Patient also tested positive for COVID-19 on 01/08/2023. GI was consulted and recommended reaching out to Surg oncology CTS as they performed his esophagectomy in April. They also recommended considering upper GI if cleared by SLP but SLP still with concerns over safe swallow making contrast intake for upper GI series risky. Surg Oncology was consulted and Interventional Pulm performed bronchoscopy on 1/11/23 and confirmed to have a tracheal defect either to the mediastinum or to the esophagus. He was kept NPO with thoracic surgery consult re: operative plan for this. (CTS) planned O.R on 1/23/23 after he was clear from respiratory isolation for COIVD. His pleuraX was drained and patient finished a course of Rocephin and azithromycin for pneumonia. Eliquis was transitioned to heparin gtt and ultimately to Lovenox bid for recent LUE dvt diagnosed in November. Patient's hospital course involved multiple surgeries including right thoracotomy, repair of TEF, cervical esophagostomy, pleural drain placements by IR, and reintubation 02/03 with subsequent open tracheostomy 02/06.  Patient was given IV antibiotics that was narrowed to Linezolid per ID until 2/20 after patient was found to have Corynebacterium striatum on Respiratory culture. Hospital course was complicated with neurology consulted for left facial droop, difficulty with tongue movement, with stroke code called 02/24 for transient neurological symptom with staring and unresponsiveness.  Symptoms resolved at the time when stroke code team arrived in the room.  NIHSS 0. CT head imaging did not demonstrate new acute changes. Continues EEG did not demonstrate any signs of seizure activity.  Otherwise, patient was in the process of prior to transferring to intensive care unit. On 02/25, it was reported that patient went to the bathroom, came back, was found grey and unresponsive per nursing staff prior to code blue being called. Code blue call 02/25, being bagged via tracheostomy tube on arrival, emergent bronchoscopy done which showed right mainstem mucous plug, aspirated with improvement in SpO2 90%. Post bronchoscopy patient's blood pressure dropped and he was started on norepinephrine, epinephrine, phenylephrine sticks given.  Bedside echo demonstrate large pericardial effusion, possible signs of tamponade.  After achieving hemodynamic stability patient transferred to intensive care unit. During ICU course, AHRF likely secondary to mucus plug and found to be positive for Stenotrophomonas pneumonia on respiratory/BAL cultures.  Patient presented with s septic shock requiring vasopressor support, was started on IV antibiotics narrowed down to Bactrim per ID for total of at least 21 days.  Patient has been having baseline tachycardia that is paced, otherwise asymptomatic. Shock overall resolve with patient successfully weaned off of vasopressor support.  Patient was initially on "difficult to wean" protocol, chest physiotherapy for support, and was eventually transitioned on T-piece and tolerated without further ventilator support escalation. He was then transferred out of ICU. Prior to ICU transfer, he underwent venous doppler of LE. He was found to have a right groin pseudoaneurysm for which IR was consulted. Patient underwent guided thrombin injection on 3/7 with IR. Repeat with small residual hematoma - no patent aneurysm. Patient incidentally was found to have a pericardial effusion, which was medically managed with colchicine per Cardiology recs. There was no evidence of tamponade. 2D Echo repeated 3/8 shows increase in size of large pericardial effusion in comparison to prior echo on 2/27 - no evidence of tamponade physiology. CTS/Cardio following. No plan for intervention. Recommend conservative management with repeat Echo in 1 month to reassess. He was also noted to have elevated LFTs.  Abdomen shows hepatomegaly, along with possible polyps vs sludge balls. Consulted general surgery for eval. D/w general surgery, recommending HIDA scan. HIDA Scan with no evidence of cholecystitis. GGT is elevated. Palliative care was consulted. Care conference with patient and his family to determine further goals of care and overall update was completed bedside 3/14. Family agreeable. He has not progressed to tolerating PMV and communicates with gestures and brief words written down. On file with 1st signature completed. Navigated discharge planning. He was scheduled for discharge, but patient noted to be hypotensive after resuming of home medications. Entresto discontinued with recommendations for resuming outpatient if indicated. He received IVF with resolution of hypotension. Report called to hospitalist. She accepted patient and advised okay to transfer.