Dr ayman elshahawy case2

1. Case report
Dr. Ayman Alshehawey
Internal Medicine & Nephrology specialist
Egyptian fellowship trainee
NMGH

2. CASE 1

3. Present history
Ashraf mohamed khalil 53 years old male
patient from mansoura known case of ESRD
on regular HD for 9 years 3 session /week
from left brachiocephalic fistula history of
HTN for 10 year and history of compansated
CLD with treated HCV 4month ago with –ve
PCR. Hx of PAF No history of DM .

4. Examination
General examination
Vital signs: BP: 130/90 mm hg PR: 84/min
RR: 17/ min TEMP: 36.6 C
Other: BW : Pre 62 kg post 59.5 kg
BFR : 300 ml/min VP : 120 mm hg TMP : 100

5. Examination
Local examination:
chest: bilateral equal air entry vesicular breath
sound.
Heart : regular S1& S2 no murmurs or added sounds.
Abdomen: lax & soft no tenderness or organomegally.

6. CNS : No neurological deficit intact power &
tone & reflexes and cranial nerve examination.
AVF : left brachiocephalic &intact skin
aneurysmal dilatation with +ve limb elevation
test & palpable thrill no signs of central vein
occlusion.

7. investigation
WBCS: 6.2 x 109/L
HBG: 7.6 gm/dl
PLATLETS: 155 x 109/L
CREAT: 8.2- 8.1 mg/dl
UREA: pre 77- post 24 mg/dl. URR 69%
Ca 9.8 – 9.5 mg/dl
Po4 : 2.3 – 2.3 mg/dl
PTH 27 pg/ml
Albumin : 3.2 gm/dl
Iron : 24 – 21 µg/dl
Transf. sat: 18.8 %

8. • Abdominal u/s:
• Liver: cirrhotic liver no focal lesion
• Spleen: enlarged size 16.5 cm
• Both kidneys: small size & lost CMD

9. • Echo. Study:
• Normal LV dimentions and functiou with EF
62%
• Atherosclerotic AV & mild MR

10. • Following drug
• L carnitine inj. each session
• Erythropioten 4000 IU twice/week
• Ferrosac amp 100mg/5ml each session
• Hepato forte cap OD
• Antodine 20mg BID

11. • Recommendation:
 holding alfacalcidol for correction low PTH
Increase dose of erythropioten for correction of
anemia target hemoglobin 10-11gm/dl
Improve nutritional status of the patient with good
healthy nutrition programe.

12. CASE 2

13. Present history
Shaban Nageeb Bedair 72 years old male patient
from Mansoura known case of ESRD on regular
HD for 6 years 3 session /week from left
brachiocephalic fistula for 5 years then Rt
brachiocephalic fistula for the last year history of
HTN for 15 year with poor compliance for
treatment& HCV not treated .
patient complain of pain and numbness of his Rt
hand.

14. And diagnosed to have carpel tunnel syndrome
undergo open carpal tunnel release surgery.
No hx of DM or CVS diseases.

15. Examination
General examination
Vital signs: BP: 120/80 mm hg PR: 74/min
RR: 17/ min TEMP: 36.8 C
Other: BW : Pre 92 kg post 91 kg
BFR : 300 ml/min VP : 130 mm hg TMP : 110

16. Examination
Local examination:
chest: bilateral equal air entry vesicular breath
sound.
Heart : regular S1& S2 no murmurs or added
sounds.
Abdomen: lax & soft no tenderness or
organomegally.

17. Examination
CNS : No neurological deficit intact power &
tone & reflexes and cranial nerve examination.
AVF : RT brachiocephalic & intact skin aneurysmal
dilatation with +ve limb elevation test & palpable
thrill no signs of central stenosis.
Rt hand index and middle finger skin changes. .

18. investigation
WBCS: 6.2-4-4.9 x 109/L
HBG: 7.6-7.2-7.4 gm/dl
PLATLETS: 332-218-204 x 109/L
CREAT: 9.1-9.7-5 mg/dl
UREA: pre 89 post 38 mg/dl. URR 58 %
Ca 9.1 – 9.9 mg/dl
Po4 : 2.7 – 2.3- 4.7 mg/dl
PTH 34.5 pg/ml
Albumin : 3.2 gm/dl
Iron : 73– 112 µg/dl
TIBC : 261
T SAT 16.7 %

19. Following drug
L carnitine inj. each session
Erythropioten 4000 IU twice/week
Ferrosac amp 100mg/5ml each session
Calcimate 500 cap 2 x 3
Antodine 20mg BID

20. Recommendation:
 holding alfacalcidol & calcium for correction
low PTH
Increase dose of erythropioten & iron for
correction of anemia target hemoglobin 10-
11gm/dl
Incease efficiency of dialysis.

21. CASE 3

22. Present history
Abo musalm ahmed 53 years old male patient
from Mansoura known case of ESRD on regular
HD for 3 years 3 session /week from left
brachiocephalic fistula history of HTN for 5 year
HCV treated4 month ago with –ve PCR twice.
No hx of DM or CVS

23. General examination
Vital signs: BP: 140/90 mm hg PR: 84/min
RR: 18/ min TEMP: 36.6 C
Other: BW : Pre 68.5 kg post 66. kg
BFR : 300 ml/min VP : 120 mm hg TMP : 110
Examination

24. Examination
Local examination:
chest: bilateral equal air entry vesicular breath sound.
Heart : regular S1& S2 no murmurs or added sounds.
Abdomen: lax & soft no tenderness or organomegally.

25. Examination
CNS : No neurological deficit intact power &
tone & reflexes and cranial nerve examination.
AVF : RT brachiocephalic & intact skin aneurysmal
dilatation with +ve limb elevation test & palpable thrill no
signs of central vein occlusion.

26. Investigation
WBCS: 6.5-5-3.9 x 109/L
HBG: 17.7-14-14.3 gm/dl
PLATLETS: 112-101-114 x 109/L
CREAT: 10.7-11.3-10.4 mg/dl
UREA: pre 128 post 45 mg/dl. URR 65 %
Ca 9.3– 9.3 mg/dl
Po4 : 4.3 – 3.3 mg/dl
UA 5.4 – 6.7 mg dl
Albumin : 4.5 – 3.9 gm/dl
Iron : 45 – 50 µg/dl

27. Following drug
Minipress 2mg OD
Alkapress 10 mg OD
Aldomet 250 mg TID
Ator 10 mg OD
L carnitine inj. each session
Calcimate 500 cap 2 x 3
Antodine 20mg BID

28. Recommendation:
Holding of erythropioten repeated
venesection in the form of get ride of dialysis
circuit blood every now and then.
Incease efficiency of dialysis.