Patient is a 60y/o F with multiple hospitalizations over the past 5months including cellulitis requiring IV abx, and subsequent C. diff colitis. Patient also has a PMH of HTN,  COPD, DJD and medically treated type B dissection below the level of the renal aa. Patient presented to the ER with low back pain/R flank pain and abdominal cramping/RLQ pain with diarrhea. The patient was febrile at rehab facility and said she had been having worsening low back pain/RLQ pain over the past few days and had "refused her oral vancomycin treatment for her C. Diff colitis".  Patient had conitnued abdominal discomfort and some generalized weakness over the past few days with reduced PO intake 2/2 abdominal cramping.

PE: 165/92, 116, 20, 10 and 96%

GEN: uncomfortable appearing

CVA tenderness on right, and mild abdominal discomfort otherwise normal exam.

W/U:

CBC 28.6<33.2>484

AN 24.2

Lac 1.2

BMP 133/3.4/94/26/34/1.63

CT ABD completed without IV contrast 2/2 CKD which showed:

"Development of the marked abnormal retroperitoneal lymphadenopathy

as described above (complete circumfrential lymphadenopathy that is circumfrential to the aorta below the level of the renal aa). Findings in the abdomen and pelvis are otherwise unchanged

from previous examination."

Image 1: CT Abd showing retroperitoneal LAD

Patient was admitted to SSU for observation for continued abdominal pain

The next day in SSU patient was well appearing in the am and became tachypneaic diaphoretic, tachycardic and hypotensive over the period of about an hourn around 1pm (this was well documented by multiple attendings around 8am the patient was fine). A code was called and although the patient was awake and responsive she appeared in severe distress c/o severe chest pain and SOB. Patients abdomen was tender to palpation, and felt firm on the right side. Central line was placed and stat labs obtained.

Patients hgb had dropped to 9.6, and lactate had increased to 5.5. BP was still unmeasurable. Chose not to intbuate and pt transferred to ICU. Patient protecting airway with a GCS of 15. Still c/o chest pain and SOB. A plan for CT chest/abd/pelvis with IV contrast planned and ordered.

In the ICU the patient became obtunded and devloped resp comprimise and was intubated. A repeat set of labs obtained showed a dropping hgb to 7.8. The intesnivist debated giving tPA, but this was held off on. (EKG showed some ST depressions but no STEMI).

A code blue was called 45 min later with ROSC after about 20min of resus. A stat TEE was performed which was negative for type A dissection to be seen. 4 units of PRBC's tx and the repeat hgb after this was 6.3. The patient coded again and was finally made DNR without resuscitation at this point.

Coroner's office report is still pending.