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Patient Case Presentation - PC
Richard C. Walls7/23/2013
Patient Demographics
• PC• 51 year old• Female• Black• 66”• 87.1 kg
• Admitted 06/27/2013
History of Present Illness
• Pt on ESRD after developing peritonitis while on peritoneal dialysis.
• Peritonitis required multiple operations, eventually leading to EC fistulae formation, eventual bowel perf, frozen bowel, and TPN dependence.
• Pt complaining of increased pain and drainage from EC fistula ostomy site w/o N/V
• Pt also complaining of pain at proline site.• While investigating these issues in ED, found to have
K+ 6.6 w/peaked T-waves
Past Medical History
• ESRD requiring iHD• Peritonitis -> EC fistulae, bowel perf, frozen bowel
-> TPN dependence• DM2 -> Neuropathy/Nephropathy/Foot Ulcers• Proline-associated cellulitis• Chronic pancytopenia• HTN• GERD• PVOD
Family/Social History
• Family History– Father – HTN, brain
cancer, DM2– Mother – Diverticulitis,
arthritis– Sister – Deceased: SLE
– Lives w/sons in Flint, recently at SNF in Saginaw
• Social History– 20 pack year smoker– Denies EtOH– Denies Illicits
Medication History• Home Medications
– ESRD• Darbepoetin 60 mcg/wk• Folic acid 1 mg daily• Paricalcitol 1 mcg w/HD
– DM2• Lantus 10 Uam, 20 Upm• Lispro 2-12 U QIDw/food• Gabapentin 300 mg daily
– Pain• Fentanyl 75 mcg/h q72h• Hydromorphone 2 mg q4h prn pain
– HTN• Amlodipine 10 mg daily• Hydralazine 50 mg TID
– GERD• Omeprazole/NaHCO3 20 mg daily
• Allergies– Ciprofloxacin –
unknown reaction– Protamine – unknown
reaction– Morphine – itching
Clinical Course
• 6/27: Presents to ED w/hyperkalemia• 6/29: Hyperkalemia resolved, line infection
IDed, vanco started• 7/2: Cultures clearing, symptoms improving,
however patient now febrile, Zosyn added• 7/5: PreHD vanco level high, dose held, patient
asked to stay an extra day due to unresolving fevers
• 7/6: Discharged to complete course of vanco
Problem 1: Hyperkalemia
• 6/27 K+ 6.6 on admission w/peaked T-waves– 1 g calcium gluconate– 10 U regular insulin– 25 g D50– Dialysis
• 6/28 K+ 5.5• 6/29 K+ 4.6• High 3s, low 4s remainder of admission
Problem 2: Proline Infection
• Pain at site on admission, cultures sent• Worsening pain and cultures w/GPC -> vanco
– 6/29 1 g– 7/1 Level PostHD 9.0 -> 1 g– 7/3 Level PostHD 17.7 -> 1 g– 7/5 Level PreHD 30.4, PostHD 22.5– Discharged to complete course (6/29 – 7/13)
• Zosyn added (febrile after vanco)– 7/2-3: 3.375 g q12– Restarted 7/5
• Proline removed 7/1 and replaced 7/3
Problem 3: Fever
• Persistent fever 7/1-2– Peaked at 39.2
• Waxed and waned remainder of admission• Associated with worsening tachycardia– HR frequently 100s-110s
• Drug Fever? Implications IF drug fever?
Problem 4: Complications of ESRD
• Anemia– Labs
• Hgb 10.2 -> 8.0• MCV 86-92, RDW 16-18
– April Labs• Ferritin 972, Tsat 67.5• B12 401, Folate 2.7
– Meds• Darbepoetin 60 mcg/wk• Folate 1 mg/day
– F/U Outpatient
• Phosphorous Clearance– Labs
• Phos 3.4-6.5• Calcium ca 9.0• Albumin ca 3.5
– Meds• Paricalcitol 1 mcg w/HD
– F/U Outpatient• Include iPTH level• May need to increase
paricalcitol dose