Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Agitation, Anticoagulant therapy, Arteriovenous fistula, Autoimmune blistering disease, Bacillus test positive
Clinical narrative: Patient is a 62 y.o. female with a history of  ESRD on HD, chronic resp failure who presented to Hospital on 7/31/2023 with c/o generalized rash.  Concerning for bullous pemphigoid, transferred to hospital 8/7/2023 for dermatology evaluation. Course complicated by cornybacterium bacteremia, then pseudomonas bacteremia, need to change HD line and CO2 retention and then COVID 19 infection.    1. Bullous Pemphigoid: p/w diffuse skin rash. History of Stevens-Johnson syndrome with metformin and warfarin.  Biopsy 8/8/23 consistent with subepidermal autoimmune mucocutaneous blistering disorder. S/p dupilumab 8/17. Doxycycline (for antiinflammatory effects) x 1 month, Nicotinamide 500mg daily till 9/16/23, mupirocin cream and triamcinolone cream advised per derm.Had hives with topicals. Derm reconsulted and advised dupixent- next dose 8/31/23. Predniosne 10mg startd 8/27/23 for urticarial features, transitioned to PO dexamethasone taper on dc. Recommended O/P age-appropriate cancer screenings. Continue Topical medicines. Dermatology clinic follow up with Dr - derm on 9/13/2023 2. ESRD with secondary hyperparathyroidism: On dialysis. Permacath placed 8/18 removed as bellow 8/29/23. HD per nephrology. DOAC restarted 9/1/23 as patient refusing subcut heparin but held again with difficulty with dialyzing through avf 9/2/23. Resumed eliquis on dc.  3. Pseudomonas bacteremia, likely CLABSI:  BC 8/23 with pseudomonas. Started on cefepime 8/23. ID continued cefepime plan 2-4 weeks. Repeat BC 8/25 and 8/27/23 +ve for pseudomonas. TTE 8/25/23 with EF 55% with no vegetations. Dialysis line removed 8/29/23. Line holiday and culture clearance. Blood cultures 8/30/23 remain negative. Cefepime 2000mg MWF after HD through 9/22/23. 4. COVID 19 positive: Fever 8/23/23- Positive  COVID 8/24 with increased O2 requirements. Started on remdesivir. Pulm stopped remdesiver 8/26/23 sec to low CrCl < 30ml. CXR not consistent with COVID picture. Isolation completed 9/4/23. 5. Acute metabolic Encephalopathy: 8/21/23- suspect sec to narcs and CO2 narcosis. Likely undiagnosed OSA. ABG 8/22 with pH 7.2, CO2 63. BH following for agitation. Patient lacks capacity. Palliative care followed for GOC.  niece is HCPOA. Haldol prn and melatonin for sleep.  6. Corynebacterium Striatum Bacteremia: OLH blood cultures + 2/2 7/31/23 and 2/2 8/2/23 with gram + bacillus. Was on antibiotics as above. Repeat blood cultures 8/8/23 2/2 with corynebacterium striatum. Started IV vanco 8/8/23. Repeat blood cultures 8/11/23 NGTD.TEE canceled due to patient refusal. 6 weeks of IV vancomycin with dialysis till 9/22/23.  7. Paroxysmal Atrial fibrillation: Per history, heart rate controlled. She was on Coumadin, but switched to Eliquis PTA. Held eliquis 8/10/23 for procedures. C2V=3 thus no indication for bridging. Patient refusing heparin. Resumed Eliquis 9/1/23 will need further hold if new dialysis line needed but with patient refusal of subcut heparin benefit > risk at this point.  8. Chronic Hypoxic Respiratory Failure:  with Obesity Hypoventilation syndrome,on home O2. H/o COPD. Possible OSA.  2-3 L NC at baseline.  BIPAP at bedtime recommended , complaince questionable. Recommend outpatient sleep study 9. Anemia of CKD: Hemoglobin in the range of 8-9. Monitored. 10. UTI: UA positive for large leukocyte Estrace, greater than 180 WBCs, 20 RBCs, few bacteria, many WBC clumps. Urine culture shows mixed flora.  Treated with Rocephin PTA