Patient Case Presentation - PC

1. Patient Case Presentation - PC Richard C. Walls 7/23/2013

2. Patient Demographics • PC • 51 year old • Female • Black • 66” • 87.1 kg • Admitted 06/27/2013

3. 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

4. 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

5. 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

6. 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

7. 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: PreHDvanco level high, dose held, patient asked to stay an extra day due to unresolving fevers • 7/6: Discharged to complete course of vanco

8. 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

9. 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

10. 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?

11. 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