Case 33: Introduction

History of Present Illness (HPI)

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A 62 year old woman with end stage kidney disease (ESKD) due to diabetic nephropathy, hypertension, and atrial fibrillation who receives in-center hemodialysis presents to the Emergency Department for severe pain in her lower extremities.

She has been on dialysis for 12 years, first through an arteriovenous (AV) fistula in her left arm which failed several years ago, and now via an AV graft in her right arm. She says she misses 1 to 2 dialysis sessions per month, and she occasionally cuts her sessions 30 – 60 minutes short. She is intermittently adherent with her medications, which include carvedilol, insulin (long-acting and short-acting), warfarin, Vitamin D, and sevelamer (phosphate binder).

She notes developing progressively worsening pain in her thighs and legs over the past several weeks. She has now started to notice some skin changes. She does not have fever, chills, nausea, vomiting, weight loss, or night sweats.  She came to the ED today because the pain is worsening and now 10/10.

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