Case 24: Introduction

History of Present Illness (HPI)

clipboard

A 60 year-old woman with end stage kidney disease (ESKD, secondary to diabetic nephropathy) on outpatient hemodialysis 3 times a week for the past year complains of chills during the last 2 dialysis treatments. You see her before initiation of her dialysis treatment today.  She receives dialysis through a tunneled dialysis catheter and is to see a vascular surgeon next week for evaluation for arteriovascular fistula (AVF) placement.

She says she feels well otherwise and says she sometimes feels tired after the dialysis treatments. She has not had any fevers at home and does not have nausea, vomiting, chest pain, shortness of breath, cough, abdominal pain, diarrhea, or rash. She has some lower extremity swelling which has not changed. She does not smoke or drink alcohol. She lives with her partner and does not have any pets.

Before you examine this patient, what is the next best step?
Send a blood cultures from the dialysis catheter venous hub and hemodialysis circuit.
Great! In a patient with chills during dialysis, we should suspect a catheter-related blood stream infection. To diagnose this, we should send cultures from these 2 locations.
Send a blood culture from the dialysis catheter venous hub.
Close! In a patient with chills during dialysis, we should suspect a catheter-related blood stream infection. But there is one approach that might be better here.
Send a blood culture from the dialysis catheter arterial hub.
Close! In a patient with chills during dialysis, we should suspect a catheter-related blood stream infection. But there is one approach that might be better here.
Reschedule her vascular surgery appointment for tomorrow.
This patient should see a vascular surgeon soon, but this is not the most urgent issue at this time. Pick another choice!
Urgently refer the patient to the emergency department.
This patient is clinically stable and there is some more work to do before urgent ED referral.
Give a dose of intravenous vancomycin and cefepime through the dialysis catheter immediately.
Though this patient may require antibiotics, this is not the next best step. Try again!
Instill an antibiotic lock in the catheter.
This intervention can be efficacious in the prevention of catheter-related blood stream infections, but is less likely to be helpful right now. Try again!

Click here for the physical exam!