Case Discussion

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ismailalamin
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Case Discussion

Unread post by ismailalamin »

59 female known htn not diabetic no other medical disorder, known normal kidney function, was on atenolol. one week ago she developed weakness in her both l.l., she gone to other doctor who gave here just multivitamins. today she presented to us with just generalized weakness, no signs of lateralization, BP: 140/90. pulse 100 reg, no fever the rest of general examination was unremarkable, we order routine investigation showed:
creat 4 -urea 170 -na 126 -k 1.2 -alt 300 -ast 700 abg: met alkalosis hco3 41
pt was admitted to ICU cvp started kcl infusion 20 mic per hour and iv saline. cvp was +7 , oliguria
we reviews her history: no vomiting no diahrea no diuritic abuse no polyuria.
on day 2 pt k: 2 creat: 6 urea: 90 na : 130 pt is still oliguric 120ml in 18 hours, cvp +12 bp 140/90

this how the pt presented to me by the phone we now have profound hypokalemia, acute renal failure
what to order next to reveal the diagnosi, what in history we should ask?
we suspected a cause for renal failure we order a test what do you think we have ordered and what was that cause?
Last edited by ismailalamin on 15 Aug 2012, 18:06, edited 1 time in total.
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Re: a real case

Unread post by einas »

renal tubular acidosis ??? salt losing nephropathy ?? what about her anion gap doctor?
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Re: a real case

Unread post by ismailalamin »

she has a metabolic alkalosis Hco3 was 41
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Re: a real case

Unread post by einas »

and chloride?
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Re: a real case

Unread post by ismailalamin »

i was told it was low but i dont remember the number but giving this a met alkalosis anion gap is of no good.
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Re: a real case

Unread post by ismailalamin »

of course cloride in urine is important here but was not done
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Re: a real case

Unread post by einas »

the hypokalemia caused the alkalosis ,,,,,, the alkalosis cause the renal failure ?! so we should investigate the causes of hypokalemia and hypertension ???
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Re: a real case

Unread post by einas »

والله يا دكتور جهجهتني عديل بقيت بعاين للمسلسل وارجع للبوست بعد شوية اسرح في المسلسل انسى حاجات البوست لكن خلاص اركز مع الكيس احسن
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Re: a real case

Unread post by einas »

checking aldosterone and renin ?
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Re: a real case

Unread post by ismailalamin »

we will search for the cause for hypokalemia next but first what was the cause of renal failure review the laps closely.
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Re: a real case

Unread post by einas »

???????????????????? renal failure high liver enzyme and old lady ???? do u mean amyloidosis ??? cant be
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Re: a real case

Unread post by einas »

خلاص غلب حماري... بالرينين والالدستيرون كنت عاوزة امشي على الرينال ارتري استينوسس هسي مخي شكلو مشى بعيد شديد للامايلويدوزس .... خلاص استسلمت طلع عندها شنو؟
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Re: a real case

Unread post by ismailalamin »

alt 300 -ast 700 creat: 6 urea: 90 k 1.2 this is the clues
we suspected rhabdomyolisis we ordered cpk
14000
mostly hypokalemia induced rhapdomyolisis.
now we need workup for hypokalemia
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Re: a real case

Unread post by ismailalamin »

liver enzymes can rise in rhabdomyolisis specially ast, also raised creat without much raised urea occur in rhabdo due to release of creatinine from damaged muscles. in the setting of hypokalemia " Potassium release from muscle cells during exercise normally mediates vasodilation and an appropriate increase in muscle blood flow . Decreased potassium release due to profound hypokalemia can diminish blood flow to muscles during exertion, leading to ischemic rhabdomyolysis".
now we solved cause of renal failure what approach for hypokalemia?
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Re: a real case

Unread post by ismailalamin »

We should ask for history of: vomiting, diarrhea, poly urea, diuretics, laxative abuse, licorice ingestion.CKD,urinary divertion,git surgeries.DM,HTN
this pt gave a history of licorice ingestion
examination: BP,Pulse, volume status, muscle
weakness. pt was htn
in hypokalemia we have 3 tools:
- Blood pressure.
- 24 Urinary potassium excretion.
- Acid-base balance.
this pt is htn, met alkalosis hypokalemia

causes of htn, met alkalosis, hypokalemia: (all will has Urinary k+ excretion >15 mmol/d).
- Surreptitious diuretic therapy in a patient with underlying hypertension
- Renovascular disease( renin high. aldosteron high)
- Cushing's syndrome( renin low. aldosteron low)
- Licorice ingestion( renin low. aldosteron low)
- Apparent mineralocorticoid excess congenital(11-beta-HSD2 deficiency) ( renin low. aldosteron low)
- Congenital adrenal hyperplasia (11 b hydroxylase deficiency, DOC high)( renin low. aldosteron low)
- Liddle's syndrome( renin low. aldosteron low)
- Renin-secreting tumors (rare ).

NB rest of causes of hypokalemia without HTN include:
if Urinary k+ excretion >15 mmol/d
** Bartter (in children with growth retardation. lasix like), Gittleman (young adult, thiazide like) has Metabolic Alkalosis(high renin !! but normotensive)
**Type 1 (distal) or type 2 (proximal) renal tubular acidosis,A salt-wasting nephropathy will has Metabolic acidosis

if Urinary k+ excretion<15 mmol/d you should consider(non renal causes ie GIT loss ) :
**lower gastrointestinal losses, Villous adenoma both has Metabolic acidosis
**Surreptitious vomiting has Metabolic Alkalosis

in this case we suspect Licorice ingestion lead to profound hypokalemia with HTN complicated by rhabdomyolysis and acute renal failure.

we need to order
ECG, urine analysis
plasma renin, aldosterone (bblockers, ACEIS should be stopped before this test, also pt need to be lying flat for 4 hours )
ca, po4, mg, cl
24 urine cortisol, cortisone, k,cl,na

as regard treatment:
pt will need HD, as with such creat in acute case like this due to tissue distruction you should start HD early.
iv fluids, kcl, mg sulfate as needed with close follow up. through central line of course.
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Re: a real case

Unread post by einas »

اعجبني جدا تسلم يدك يا دكتور
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Re: a real case

Unread post by thuraiaibrahim »

السلام عليكم ..
راااااااائع التقديم و التوضيح ...
..نتمنى لك التفوق و التوفيق دائما
إيناس إزيك .. خليتى الدكتور كشف لينا الأوراق سريع ...كان تخلى الناس تجى تمخمخ شوية..لك تحياتى و ودى * ..
لكن والله انا الليكورايس ده ما كنت عارفاهو شنو ذااااتو ..وكنت متخيلة انو مصيبة بيشربوها الخواجات ..لكن لما لقيت الدكتور شغال فى مصر قمت سألت قوقل فاتضح انه (عرق السوس)
)
قد يكون عرق السوس
LICORICE
مفيداً، الا أنه قد أثار جدلا كبيراً. فالمدافعون عنه يشيرون إلى أنه قد استعمل في أنحاء العالم لالاف السنين في علاج السعال، البرد، الطفح الجلدي، التهاب المفاصل، الالتهاب الكبدي، تليف الكبد، حالات العدوى، بينما يصر النقاد_مع إعترافهم بفعالية العشب_على أن له آثاراً جانبية قد تهدد الحياة، مما يجعله غير آمن الاستعمال. وفي عدد قليل من الحالات، فإن مستخلص عرق السوس المركز، المستخدم كمنكه للحلويات، قد سبب بعض الضرر عندما تم تناوله بكميات كبيرة. على أية حال، فانه بالنسبة للبالغين الاصحاء الذين يتناولون عرق السوس باعتدال فان له منافع كثيرة تتجاوز المخاطر التي قد يسببها.
..****************

برغم مخاطرةعرق السوس المعلنة الا أن إدراة الغذاء والدواء الامريكية
fda
قد أدرجت العشب ضمن قائمة الاعشاب آمنة الاستعمال بشكل عام .بالنسبة للبالغين _باستثناء الحوامل أوالمرضعات _ الذين لايعانون من السكر أوالجلوكوما أو ارتفاع ضغط الدم أو أمراض القلب أو السكتات الدماغية والذين الايعالجون من أمراض الغدة الكظرية فإن عرق السوس يعتبر آمنا بالنسبة لهم إذا استخدم بحذر ولمدة قصيرة وبالجرعات الموصي بها تماما. استشر طبيبك قبل تناول الجرعات العلاجية من العشب .إذا سبب لك تناول العشب اضطربا بسيطا مثل اضطراب المعدة أوالاسهال ،فعليك بتقليل الجرعة أو الامتناع عن تناوله نهائيا .أخبر طبيبك إذا شعرت بأي أعراض جانية أو إذا لم تتحسن الاعراض _التي من أجلها استعملت العشب_بصورة واضحة خلال أسبوعين .
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Re: Case Discussion

Unread post by SudaMediCa »

Great post, we wish all posts in the site are useful as much as this one

well done, thanks doctors for the great discussion
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Re: Case Discussion

Unread post by Dr.Sudan »

:D :D :D
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Re: Case Discussion

Unread post by thuraiaibrahim »

سعادتك د.سودان :- استمتع بالعرديب يا سيدى فهو التمر هندى
... و مختلف تماما عن العرق سوس ..
ننتظر تفصيلا من فطاحلة الأعشاب و الصيدلة ..
مع تحياتى ..
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Re: Case Discussion

Unread post by ismailalamin »

Image
Image

this is the ecg of this case
notice prolonged QT more than 600 m.second
also inverted T waves with U waves in lead V2-6 .
depressed ST segment V5,6 (can occur with severe hypokalemia)
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Re: Case Discussion

Unread post by ismailalamin »

a similar case scenario in MRCP exam but cause here was hypothermia, this people asks the right questions
A 55-year-old homeless male was found stuporous and smelling of alcohol.
Observations in the emergency department reveal a core temperature of 34°C, a pulse of 50 bpm and blood pressure of 116/80 mmHg. Dipstick urine analysis shows blood +++.

Some of his investigations are listed:
Creatinine 320 µmol/l (60-110)
Gamma GT 40 U/l (10-40)
AST 550 U/l (1-40)
LDH 1500 U/l (10-250)

Urine microscopy no cells or organisms.

What is the most likely cause of the raised serum creatinine concentration?

(Please select 1 option)
Chronic renal failure
Dehydration
Hypothermia
Paracetamol poisoning
Rhabdomyolysis
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