68 you female with purpura to arms and chest | Figure 1

APRN4CHRIST

Nurse Practitioner

68 yo female with purpura to arms and chest

68 yo female in LTC with past medical hx of ESRD on HD, A.Fib, HTN Heart disease with HF and CKD, COPD, morbid obesity, protein deficiency and Anemia of Chronic disease. Was hospitalized for 4 days 1 week ago for severe edema both Upper and Lower extremities along with 3rd spacing. She was dialyzed InPt and also dx with UTI. She was started on Linezolid and Ertapenem. She is also taking megace, midodrine, protonix, allopurinol, apixaban, amiodarone, Norco, doxepin, clonazepam, furosemide, amitiza, sertraline,.. She was sent to ER on Saturday from Dialysis for uncontrollable bleeding around her tunneling dialysis catheter. She returned without any new orders. I placed her eliquis on hold. She developed a skin tear from her iv removal and the nurse had difficulty stopping the bleeding so a pressure dressing was applied for 10 min and bleeding stopped. Received these pictures today and the resident was sent to the ER. She returned with negative venous doppler of the left hand and "normal labs" at the ER which I do not have access to. Her skin is now (for lack of a better word) crispy. It is cracking and she has serosanguinous fluid leaking from both arms. I now have all medication on hold and have arranged for direct admit in the morning. But I would like to have any suggestions on what is going on dermatologically.

The author made 3 updates to this case

Update 1

She was admitted early this AM. No word from admitting physician as of yet.

Update 2

So she has been dx with Thrombocytopenic disorder. After her initial ER visit with normal platelets, they dropped to 69; she has developed severe post hemorrhagic Anemia with her Hemaglobin dropping from 11 to 7.9 in 48 hours. Her K has also dropped to 2.9, usually running around 4.0. She has nephrology in on her case. They are speculating that the combination of Linezolid, Apixaban, and heparin led to the coagulopathy. I will note that her AST/SGOT is mildly elevated at 42 but her Trigs are grossly elevated at 697. This was not present at her last lipid panel 9 months ago.

Update 3

Final update. Final dx Thrombocytopenic disorder, Blood loss anemia, and ESRD. She has remained hospitalized through tomorrow. She has slowly declined into unresponsiveness. She has had several blood transfusions due to the steady decline of her H/H. Her platelets have never recovered. I almost feel like it's an aplastic anemia. Her family has declined to search for the cause of the blood loss and declined further testing. She is now DNR and is coming back on Hospice with comfort measures only.

Diagnosis Added