Dr farrag case
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This patient presented with symptoms of difficulty breathing, lower limb swelling, decreased urine output, and pallor. Her labs showed kidney dysfunction with elevated creatinine and liver enzymes. Her history of abruptio placenta and recent pregnancy termination suggested HELLP syndrome. A kidney biopsy was considered but the patient refused. Her kidney function and labs gradually improved with aggressive fluid management and medications.
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Dr farrag case
- 1. Dr. farrag megahed Nephrology Resident Mansoura NEW General Hospital Case Presentaion
- 2. • A30- year -old female was referred from Elmania University Hospital for OPINION with chief complaints • Difficulty of breathing • Swelling of both lower limb • Decrease urine out put • Sever pallor • 10 days ago
- 3. Personal history • Patient named Shimaa Gamal Faez Married since 10 years ,has 2 off spring youngest 7 years old,house wife ,no special hapits of medical importance.
- 4. Past history No similar condition No history of drug intake • No history surgical operation except c.s.
- 5. Family history • No history of similar condition
- 6. Obstetric history • She is G3 P2 .abortion occur at 7th month of last pregnancy as diagnosed by abruptiou placenta resulting in haematoma and termination of pregnancy due to intrauterin fetal death by C. S.
- 7. PRESENT HISTORY • The Condition started by dyspnea which increasded gradually,progressed course associated with vomting and heart burn 2week ago . There is no respose for ttt ,she became fatigued and abdominal pain.. On Abdominal ultrasound examintion found abruptio placenta and intra uterin fetal death which leading to terminatin of prgnacy by C.S. ,lab investigation show elevation of seum creatinine ,liver enzymes and sever anemia,she also was olgiuric ,no hypertension ,no diabetus melletus
- 8. General examination • Patient is consious ,alert ,oriention to place time person,orthopenic • Blood pressure 130/90 • RR=20 • pulse=80 • Temperature 37
- 9. Local exaination • HEAD NECK: congseted vein ,no neck swelling • Chest vesicular breathing with decrease bilateral air entry and diffuse crepitation. • Heart normal S1 & S2 no murmurs or added sound • Abdomen lax & soft ,C.S.scar • NOtenderness & no organomegally • Lower limbs bilateral LL pitting odema below knee,intact peripheral pulsation
- 10. Investigation • Lab.. • Hb7.5 WBCs 9.7 Plt 50 • Urea190 Creatine5.2 Na143 K=4.1 ,Ca=8.1 Po4=4.8 • Albumin 3.2 • ALT(sgot)119 AST (sgpt)100 • CRP 110 • ABG PH 7.22 Pco2 25 Hco3 10.5 • INR 1 • URINE :RBCs 35 albumin ++ pus 30 granular cast
- 11. Investigation con. • ABD.US • LIVER:averge size ,homogenousechopattern ,no focal lesion ,normal pv, • Gb:averge size ,nomud or stone.normal CBD • SPLEEN:average sizeomogenousS echopattern NO focal lesion • Rt kidney size averge 14x4x1.7 increase ecogencity grade I nostone,good CMD • Ltkidnysize averge 11x5x2 incraese echogencity gradeI ,no stone good CMD • UBEMPTY • Moderate bilater pleuralleffusin • mild hepato renal fluid • Uterus bulky with irregular anterior wall • Small collection is seen measureing 2.4x2.4cm in cui-de-sac
- 12. Q1 What is your differation diagnosis?
- 13. DIFFERENTIAL DIAGNOSIS •Pre renal •renal • 1-HELLP Syndrome • 2-thrombotic microangiopathies (TMA) • 3-acute tubular necrosis (ATN)
- 14. TMA • Consist of • thrombocytopenia • Microangiohemolytic anemia • Microvascular thrombosis • LAB of TMA • Sever thrombocytopenia-anemia • Reticulocytosis • Elevated LDH • Normal liver enzyme • Creatinine elevation in renal involvement • Treatment • Urgent empirical plasmapharesis
- 15. HELLP Syndrom. Hemolysis .elevated liver enzyme .low platelets with hypertensive disorder of pregnancy .though to be a sever form of pre eclamptic liver dysfunction but it can occure in normotensive as well .Symptoms Abdominal pain Nausea and vomting With or with out jaundice
- 16. HELLP SYNDROME con. Diagnosis Hemolysis Serum LDH>600u/l Characterstic peripherial blood smear Elvated liver enzyme serum aminotrans ferases >70 Low platelets <100 Majority ocuring of pregnancy in 3rd trimester Management Close monitor of patient End pregnancy Steroids Prophylaxsis anti biotic
- 17. Acute tubular necrosis • Most common cause of AKI • 1-olgiuric (2-4weeks)—a-ischemic b-toxic • 2-polyuric (3-4)day • 3-post diuretic • Investigation no biopsy needed • Urine :granular cast due to dilatation of healthy nephron • Sonar normal • Blood urea ,creatinine increase,Hb% decrease,k and po4 increase, ca++decreae
- 18. Q2 •What further investigation you would carry out?
- 19. FURTHER INVESTIGATION DONE • LDH =1533 • VIROLOGY HCV –ve,HBV -VE • ANTI DS DNA -VE • C3,C4 NORMAL • ANA -VE • Blood film( lieshman stain): • blood film shows marked variation in size and shape of RBCs some cells show central pallor,few fragmented cell(shistocytes)are seen, WBCs show leucocytosis with absolute neurophilia,mature segmented cell with some toxic granulation ,platelets are seen with normal granularity and no aggregations,manual platelets cout :110.000/cmmfollow up is recommeneded,exclude microagiopathic anemias??
- 20. Q3 •Would a kidney biopsy help ?
- 21. HOSPITAL COURSE • The patient has been admitted to nephrology • departement on 9/03/2018 • Fluid ,blood trans fusion and antibiotic were intiated • Follow up on regular haemodialysis on 10/3 lasix 40mg /8hour ,and solupred 20mg 3x1 on 11/3 STOP previousS AB and add.cefipim 1gm iv /24,levofloxacin 500mh iv /24hour, on 11/3 add aldomet 250 mg 1x3 0n 14/3 add alkapresss 10mg 1x1 on 29/3 partial improvement occur • During this period decision was taken to do renal biopy but patient refuse , …patient was discharged on 2/4 with follow up in out patient clinic on with creatinine2.7,Hb =8.2 plt=84 • Solurpred 20 1x2 • Alkapress 10tab • Rantidine 150 tab • Motilium syrup
- 23. Fluid chart of patient during ttt• oliguric • 1)10/3 input 600out put 150 • 11/3 input 450 out 200 • 12/3input 1300 out put 400 • 13/3 intake 500 out 150 • 14/3 input 800 out put 700 • 15/3input 700 out 500 • 16/3 in put 400 out put 500 • 17/3 input 400 out 600 • 18/3 input 200 out put 600 • 20/3 input 550 out put 1250 • 22/3 input 1600 out 1600 • 23/3 input 1800 out put 2000 • 24/3 input 1900 out put 2300 • 25/3 input 2200 out put 2500 • 26/3 input 2000 out put 2500 • 27/3 input 3650 out put 5000 • 28/3 input 3300 out put 4500 • 29/3 input 1300 out put 1600 • 31/3 input 1050 out put 1700 • 1/4 input 2300 out put 1500