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