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/NaHCO 3 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: 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

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