Dr ayman elshahawy case

1. Case presentation
Dr.Ayman Alshehawey
Nephrologist

2. Personal History
*33 years old male patient from AL Mahala
lawyer, married and have 3 children ex
smoker 4 months ago.

3. Complain
Swelling of his lower limbs with
generalized fatigue.

4. Present history
The condition started about 3 month ago with
gradual onset and progressive course of
swelling of his lower limbs and easy fatigue.
patient has been admitted to other hospital and
received 7 HD for 1 month then stopped.
on 8/11/2017 patient readmitted to our hospital
with the same complain associated with sever
diarrhea 7-8 LBM per/day.

5. Past history
• SLE since 2003 with LN
(WHO. Class IV). 2 times biopsyes on 2003 &
2017.
• Hypertension for 7 years.
• No past history of similar condition
• No previous surgical intervention

6. family history
No similar family history
-VE consangunity

7. Drughistory
• Sulipride 20mg OD
• Imuran 50 mg from 2003-6/2017
• Cellecept 250mg BID from 6/2017
• Hydroquine 200mg
• Aldomet 250mg TID
• Nevilob 5mg
• Eprex 4000 IU
• Ator 10mg
• Folic acid 500mcg BID
• Calcimate cap 500mg BID

8. examination
• General examination:
* Patient was fully conciouss, alert,
oriented, cooperative, normal decubitus,
but looks very ill and underweight.
* Neck examination: normal JVP. No
palpable mass

9. examination
• Vital signs:
BP: 160/90 mmhg
PR: 76/min
RR: 18/min
Temp: 36.9c
O2 Sat: 99% on RA

10. examination
• Local examination:
Chest vesicular breath sound bilateral
equal air entry.
Heart normal S1 & S2 no murmurs or
added sounds
Abdomen lax & soft & loins tenderness
&no organomegally.

11. examination
• Local examination:
CNS normal reflexes ,power ,tones
and cranial nerves, no other
neurological deficit
Lower limbs bilateral LL. pitting
odema below knee intact peripheral
pulsations.

12. investigationsWBCS: 1.3- 2.5 -2.4 -2.6 -2.5 -2.9ₓ109/L
HBG: 7.8- 8- 8.5- 8.1- 8.1- 8.4- 8.3 g/dl
PLATLETS: 57- 91- 123- 144- 184- 182- 189
CREAT: 8.6- 7.7- 9.4- 10.5- 11.2- 10.5- 8.9 mg/dl
UREA: 127- 200- 156- 190- 232- 229- 191 mg/dl
K : 2.8- 3.2- 3.5- 4- 3.3- 3.3- 3- 3.4 mg/dl
Na : 134- 133- 141- 140- 130- 131- 133 mg/dl
Ca 8.6- 7- 7.8- 8.5 mg/dl
Po4 : 8.6- 13- 8.6- 7.7 mg/dl
Cholestrol : 141mg/dl
INR : 1.29
Albumin : 1.8 g/dl
ANA & ANCA : Negative
C3 & C4 : WNL
LFT : WNL

13. RADIOLOGY
Abd.U/S :
Liver : average size, normal texture , no focal
lesion normal intrahepatic radicle and CBD.
Kidneys : average size kidneys, poor CMD, grade
III nephropathy and no back pressure no stones.

14. Renal biopsy
On 9/8/2017
• Lupus nephritis WHO class IV.
Activity index ------- 10/24
Chronicity index ------ 5/12

18. HOSPITALCOURSE The patient has been admitted to nephrology departement on 08/11/2017 in
isolation room for further investigation & management. Cellecept holded to
control diarrhea (improved)&hydroquine to decrease BM suppression on the
following treatment.
• sulipride increasesd to 60 mg OD
• vanco. 500 mg IV then oral / 6h
• flagyl 500 mg IV /6 h then oral
• imodium 2mg
• Nevilob 5mg OD
• Aldomet 250mg TID
• NaHCO3 cap TID
• Calcimate 500mg cap TID
• Erythropioten 4000IU every other day
• Ferroglobin cap OD
• Folic acid 1000 mcg BID
• Ator 10mg OD

19.  Patient recived 5 HD sessions via temporary RT IJV
catheter and planned for AVF creation.
 On 17/11/2017 patient seen by hematologist for
pancytopenia and advise to start imuran to decrease lupus
activity inspit of ( -ve ANA&ANCA and normal C3&C4) but
no yet started .
 On 20/11/2017 patient showed (sever
hypoalbuminemia) 1.8gm/dl received 4units FFP / 12H and
human albumin 20% / 24h.