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Richard C. WallsPatient Case PresentationPC: 51 yo black F; admitted 6/27/1387.1 kg, 66”CC: Abdominal pain, ostomy leakage, hyperkalemiaHPI:Hx ESRD(iHD), DM2, HTN, fungal/MDR-bacterial peritonitis requiring multiple operations leading to enterocutaneous fistula and TPN-dependence.Peritoneal dialysis -> Peritonitis (MDR citrobacter, bacteroides, enterococcus, candida) -> iHDFollowing resolution, developed surgical complications (bowel perforation) -> G-tube & wound vac. TPN-dependent due to frozen bowel. Plan for surgical takedown of EC fistula 09/2013.2 wk PTA: clear liquid diet po -> full liquid -> 1 wk PTA leakage from ostomy bag, irritating abdomen (green/yellow drainage larger in volume than usual), only local pain, no N/VReports pain at proline site, no redness/swelling/drainage (treated 2m PTA w/vanco, line not removed due to limited access). Afebrile, no chills/nightsweats.ED for management of ab pain/leakage, K+ found to be 6.7 w/peaked T-waves, leading to admission. Received calc gluconate, insulin, D50, 30g Kayexelate, and dialysis.PMH:ESRD iHDMDR peritonitis -> EC fistulas, bowel perf, frozen bowl; TPNDM2 w/neuropathy/nephropathy/foot ulcersProline-associated cellulitisChronic pancytopenia due to ESRD & infectionHTNGERDPVOD (Pulmonary venoocclusive disease)F/SH:Father—HTN, brain cancer, DM2; Mother—Diverticulitis, arthritis; Sister—Deceased SLE20 py smoker, no EtOH/illicits; lives with sons in flint, SNF in Saginaw recentlyHome Meds:Darbepoetin alfa 60 ?sq weeklyInsulin - Lantus: 10 Uam, 20 UhsInsulin – Lispro: 2-12 UQID w/mealGabapentin 300 po qdFentanyl 75 ?/h q72 hHydromorphone 2 po q4h prn painAmlodipine 10 po qdHydralazine 50 po TIDOmeprazole/NaHCO3 20 po qdFolic Acid 1 po qdAllergies:Ciprofloxacin (reaction unsure)Protamine (reaction unsure)Morphine (itching)Clinical Course:6/27ED: K+ 6.6; proline site pain -> blood cultures; sysP(80s-90s) overnight6/28K+ 5.5 TPN resumed with reduced K+; Increasing proline site pain6/29K+ 4.6. Cultures grow GPCs; 1g vanco (11.4 mg/kg) cultures redrawn; pain worsening, refused TPN6/30Much improved symptoms, cultures -> coag negative staph; plan for 2 wks of vanco from first negative culture7/1Continued symptom resolution, post HD vanco – 9.0; redosed 1g; proline removed7/2Fevers overnight w/Stachy, recultured, Zosyn added7/3Isolated fever, Zosyn d/ced due to lack of culture growth/gram- suspicion, proline replaced, preHD level 25.5, post HD level 17.7, redosed 1g7/4Afebrile overnight, occasional tachycardia7/5Fever overnight w/tachycardia, preHD level 30.4, post HD level 22.5, patient cried because she had to stay another day due to large number of iatrogenic complications7/6Discharged to complete course of vancomycinProblem List:1. Hyperkalemia6.6 in ED w/peaked T-wavesManaged with 1 g calcium gluconate, 10 U regular insulin, 25 g D50, & dialysis5.5 -> 4.6 over 48 hStable for rest of admission in high 3s, low 4s2. Proline Associated BacteremiaPresented initially as pain and not treated, although cultures collected.2 days into stay, patient exhibiting signs of sepsis (hypotension, tachycardia, thrombocytopenia), and blood cultures grow coag negative staph, 1g vanco 6/29.Symptoms improve, 7/1 vanco post HD 9.0, 1 g redose, proline removed.Pt becomes febrile, Zosyn (3.375 q12) added, d/ced next day due to no culture growth.HD levels 25.5/17.7 pre/postHD 7/3, redosed 1gFevers begin again, patient shows preHD level 30.4, post HD 22.5, dose heldPatient discharged to complete dialysis dosed vanco regimen until 7/13.3. FeversFirst present on 7/1 after vanco re-dose, resolve 7/2 afternoon.Isolated fever on 7/4, through 7/5 eveningNo culture growth apart from initial S. epi. despite sampling HD cath, proline.Leading suspicion is that vanco caused fevers, may want to consider linezolid/daptomycin based on situation for patient in future.4. ESRDHgb 10.2 on admit, fairly steady decline throughout admission down to 8.0 on 7/6Some dilutional effect due to fluids (WBC 7.5 on admit, down to 2.9 on 7/6)MCV 86-92, RDW 16.4-18.0, 4/21—FRTN 972, TSAT 67.5, B12 401, Folate 2.7Continue darbepoetin 60 qweek, f/u outpatientPhos 6.5-3.4, Ca++ ca 9.0, Alb ca 3.5Continue paricalcitol 1 MWFw/HD, obtain iPTH outpatient & assess dose ................
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