Dr mohammed alkoddousi case

1. Case presentation
Dr. Mohammed Maged Al Koddousi
Egyptian Nephrology Fellowship Trainee
New Mansoura General Hospital
Nephrology Department

2. Personal history
59 years old male patient from Mansoura,
work as a seller , divorced from 15 years ago ,
have one son 30 years old , smoker from 25
years ago , he smokes about 40 cigarettes per
day .

3. • Swelling of both lower limbs
• Difficulty of breathing

4. Present history
• The condition started about one month ago with gradual onset and
progressive course of swelling of his lower limb associated with
difficulty of breathing , dry cough and easy fatigue
Associated with decrease urine output.
• No history of DM
• No history of HTN

5. • In 31 Octobor investigations
done :
Serum creatinine 3.8
Blood urea 48
Serum uric acid 6.9
SGOT 35
SGPT 39
Serum albumin 3
Serum bilirubin 0.8
Random blood sugar 136
HCV Ab negative
Serum calcium 7.7
Hemoglobin 8.2
MCV 58
TLC 8700
Platelets 345
Blood group AB+
AFP 9.6
Serum cholesterol 127

7. Past history
•History of NSAIDs overuse from 10 years ago .
•No past history of similar condition .
•No past history of any surgical interventions .

8. Family history
No family history of similar condition .

9. Drug history
Lasix 40 mg 1*1
Lipona 20 mg 1*1
One alpha 0.25 ug 1*1
Calcimate 500 mg 1*3
Neuroton tab 1*1
Erythropiotein 4000 I.U. S.C. every week
Haemojet amp. Every 10 days

10. Examination
•General examination :
Patient was fully conscious , alert , oriented ,
with depressed mood ,
Appearing very ill , obese, orthopnic and
pallor .

11. •Vital signs :
Blood pressure : 110/70 mm/Hg
Pulse : 103 / min.
Respiratory rate : 16 / min.
Temperature : 37

12. •Local examination :
Chest ---- bilateral fine basal crepitations and wheezy chest
Heart --- normal S1 and S2 , no murmurs or added sounds
Abdomen  normal contour of the abdomen, no scars, no
pigmentations , no pulsations, lax and soft
Lower limbs - bilateral pitting edema of both lower limbs
below knee , intact peripheral pulsations

13. The following investigations was
done before the admission of the
patient
(admitted in 9th December 2017)

14. Lab investigations
• Blood chemistry and Electrolites :
Serum creatinine 10.3
Blood urea 161
Serum Na+ 132
Serum K+ 5.3
Serum calcium 6
Serum phosphorus 9.2

15. • CBC :
WBCs 17.4
HGB 7.2
MCV 74.4
PLT 536

16. • ABG :
PH 7.12
HCO3 7.2
PCO2 22

17. Urine analysis

18. ECG

19. Chest X Ray

20. Abdominal Ultrasound
•Right kidney : 9 * 3.9 cm , poor CMD , no
back pressure , no stones .
•Left kidney : 6.3 * 4 cm , poor CMD , no
back pressure , no stones .

21. Management
• Insertion of temporary hemodialysis catheter
• Urgent hemodialysis session
• Nebulizer every 6 hours
• Cefepime 1gm every 24 hours
• Levofloxacin 750 every 24 hours
• Acetyl cysteine sachets every 8 hours
• Zantac 150 amp every 12 hours
• One alpha .25 ug every day
• Calcimate 500 mg every 8 hours
• Fluid chart
• Follow up Bp,Temp,Pulse every 6 hours

22. Lab Sequence
HGB TLC PLT CREAT UREA NA+ K+ PH HCO3 PCO2 INR
9/12
7 18 465 10.3 161 132 5.3 7.12 7.2 22 1.3
10/12
7.2 17.4 536 9 146 129 4.3 7.19 12.7 23 1.5
11/12
6.8 15.9 474 9.2 145 145 4.3 7.11 13.7 25 1.59
12/12
6.8 14.6 521 8.5 145 135 4.4 7.27 12.4 24 1.4
13/12
6.8 15.5 618 6.6 107 135 3.4 7.29 16.8 35 1.28
14/12
6 16.7 575 7 172 142 3.6 7.21 17.6 44 1.33
15/12
4.4 12.9 265 5.5 80 126 3.3 7.35 25 40
16/12
7.2 20.6 461 4.9 56 131 3.7 7.21 17.6 44

23. • Differential leukocytic count :
Relative Absolute
LYM% 12.6 L (20-45) 2104 (1500-
4000)
NEU% 80.3 H (40-75) 13410 H
(2000-7500)

24. Periphral Blood Film
•RBCs : markedly anisopoikilocytosis with fragments
cells .
•WBCs : mildly increased and most of cells are
neutrophils with toxic granulations .
•Platelets : normal distribution in film with gain
forms
•Anti dsDNA, Hb electrophoresis are recommended.

25. •ESR 135
•LDH 753 (normal 50-240)
•Alkaline phosphatase 224 (normal 25-115)
•Reticulocyte count 2.6 %
•T.Bilirubin 0.9 D.Bilirubin 0.3
•Serum Albumin 2

26. Anti ds DNA –ve
HIV -ve
HBs Ag -ve
Direct Coomb’s Test +ve
Indirect Coomb’s Test -ve

27. Echocardiography
• Rim of pericardial effusion around
the heart about 5 mm
• No compression on the right
side of the heart .

28. Chest X ray after 4 days of admission and daily
dialysis

29. Hospital Course
• The patient is admitted in nephrology department in 9th of December
and received daily hemodialysis via temporary RJC. and received 2
packed RBCs. Due to drop of his hemoglobin .
• In 11th December patient seen by pulmonologist and advised
nebulizers and the same antibiotics which he is on.
• In 12th December patient is seen by cardiologist and
echocardiography done (rim of pericardial effusion 5mm)
• In 14th December the patient seen by hematologist and peripheral
blood film was done and recommended anti ds DNA, HB
Electrophoresis .

30. • The patient is on the following regime of TTT:
Nebulizer every 6 hours
Cefepime 1gm every 24 hours
Levofloxacin 750 every 24 hours
Acetyl cysteine sachets every 8 hours
Zantac 150 amp every 12 hours
One alpha .25 ug every day
Calcimate 500 mg every 8 hours
Fluid chart
Follow up Bp,Temp,Pulse every 6 hours

31. DD of Autoimmune hemolytic Anemia
• Warm type : idiopathic – Chronic lymphocytic leukemia –
Lymphoma – Alpha methyl dopa
• Cold type : viral infection e.g. IMN – Mycoplasma pneumonia .