Case 27 – History


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Case 27



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Brief History

The patient was a young African American woman with congenital, familial kidney disease requiring dialysis, status post two shunts (including a HeRO graft) and an arterio-venous fistula in the left arm.

Each of these clotted.

When second shunt in the arm clotted, a temporary intravenous vascular site was inserted into the right neck prior to a new (third) shunt being placed in the left thigh.

This third shunt remained patent and functional.

The patient’s course was also complicated by pulmonary embolism (suspect origin: the clotted HeRO graft).

For her pulmonary embolism, the patient was started on Coumadin and home oxygen.

There was consideration of operative removal of clots.

For unknown reasons, the patient’s Coumadin was discontinued approximately 6 months after the onset of the pulmonary embolism.

Approximately two months after Coumadin was discontinued, the patient became hypotensive and short of breath at the end of a dialysis session.


Partial dialysis records – day of death




Dialysis Clinic Notes – day of death




Emergency Services Trip Record – day of death





The patient died despite resuscitative efforts.


Next: External exam

Discussion Questions

1. Summarize the history.

2. Based on the dialysis record, why was dialysis terminated early?

3. Review the records and decide how much time elapsed between the end of dialysis and the time the paramedics were called? What explains this? Is there a concern?

4. Whose responsibility is it to call 911 in a dialysis center or any outpatient or medical facility? What if the patient does not want 911 called? What is the right decision?

5. What is the difference between the initial Clinic Notes and the revised Clinic Notes from the dialysis center on the day of death? Why do you think these changes were made?

6. How does the Emergency Services Trip Record contribute your understanding of the events?

7. What would you have done differently in the dialysis center?

8. What ethical issues does this case present?

9. What’s the difference between a dialysis shunt, graft and fistula?

10. What are common complications of each?

11. This patient had three operations for dialysis access. Each clotted and stopped working. How might this relate to the patient’s clinical history?

12. What is a HeRO graft?

13. What are some common causes of kidney failure?

14. What emergencies can be associated with kidney failure?

15. What emergencies can be associated with dialysis?