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CASE PRESENTATION A 52-year-old woman came to the emergency department (ED) for hemodialysis (HD) due to end-stage renal disease (ESRD). She had spent the preceding several weeks in an outside hospital being treated for pneumonia and bacteremia with daptomycin. She subsequently left against medical advice (AMA) after having her dialysis access catheter removed. She presented to our ED because she needed HD vascular access placement and re-initiation of dialysis treatments. Her medical history included chronic kidney disease secondary to hypertensive nephrosclerosis, anemia, hypertension, deep venous thromboses (DVT), systemic lupus erythematosus, and a seizure disorder of unknown etiology. The patient, a Jehovah’s Witness, refused blood transfusions; therefore, her anemia was being treated with intravenous (IV) administration of iron, epoetin alfa, and folate. Other medications included nifedipine, clonidine, metoprolol, sevelamer, and prednisone. She was allergic to amoxicillin, azithromycin, hydralazine, labetolol, linezolid, morphine, and vancomycin. She reported previous IV heroin use many years earlier and previous cigarette smoking. She denied alcohol use or any current drug or tobacco use. Upon arrival, she was alert and in no acute distress with a fever of 38.3° Celsius, heart rate of 87 beats per minute (bpm), blood pressure of 110/65 millimeters mercury (mmHg), respiratory rate of 17 breaths per minute, and pulse oximetry of 99% while breathing room air. She weighed 80 kilograms and was 5 feet 6 inches tall. Her head was normocephalic and atraumatic with moist mucous membranes. Pupils were anicteric, equal, round, and reactive to light and accommodation. The neck was supple and without lymphadenopathy or tenderness. Her lungs had coarse breath sounds with mild bibasilar crackles but no wheezes or rhonchi. There were no retractions or increased work of breathing. Her heart was of regular rate and rhythm without murmurs, rubs, or gallops. Her abdomen was soft with normal bowel sounds and without distention, tenderness, rebound, or guarding. University of Maryland Medical Center, Baltimore, Maryland University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland * †

52-Year-Old Jehovah’s Witness Female with Weakness