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