A Former Cocaine User Whose Specialist Told Her She's Dying

Catherine M. Divingian, MD, PhD; Mityanand Ramnarine, MD; Jeffrey Jordan, MD

Disclosures

February 02, 2021

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us .

Background

A 66-year-old woman presents to the emergency department (ED) directly from her nephrologist's office. She says, "My kidney doctor told me that if I do not come in here, I'll die!" She is asymptomatic, and an examination of all her systems is negative.

The patient has no history of sudden weight loss, fever, chills, nausea, vomiting, palpitations, focal neurologic or cognitive deficits, headache, dysuria, hematuria, polydipsia, and polyuria. She claims that she feels fine but is alarmed by her nephrologist's insistence that she go to the ED immediately.

The patient has a history of type 2 diabetes mellitus (DM2); stage IV chronic kidney disease (CKD); essential hypertension; and two basal ganglia strokes, which occurred 3 and 4 years earlier. She was told that she was not a candidate for dialysis, and her CKD has not progressed significantly over the past 3 years. A neurologist determined that her strokes were likely caused by previous drug and tobacco use. She has no history of any cardiac disease.

Her medications include insulin glargine (15 units every night), lisinopril (40 mg), and omeprazole (10 mg). She recalls that her most recent A1c was 8.9%, and her blood glucose level remains below 170 mg/dL. Her only surgery was the cesarean delivery of her daughter 30 years earlier.

The patient is a former smoker with a 45-pack-year history and was a heavy cocaine user until she had her most recent stroke 3 years prior. She currently does not take any illicit drugs and drinks only a glass or two of wine on weekends. She has no known drug allergies. Her family history is positive for DM2 on her mother's side of the family. Her father had a myocardial infarction in his late 70s.

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