ID: (Tacca462Integrifolia)
For patient's online record click here
Global conversational clinical decision support:
For patient's online record click here
Global conversational clinical decision support:
Kausik Khan (UK) it sounds like a bit longer story of 15 days of renal problem. When was the abortion happened? if that is the only significant history then should think about post infectious glomerulonephritis or possibly toxin induced |( not sure what was the method ...See More
Rakesh Biswas Thanks Kausik, It appears that she took 4 pills to induce an abortion a month back (right Prakhar?) and was kidnapped 3 months back. She too the pills almost a month after the exposure. Her TLC is remarkably normal to think of a septic abortion (in retrospect)? Still not able to join the dots between this history of abortion, acute renal failure needing dialysis and the ovarian mass with collection. (Sujoy?)
Kausik Khan Could PID a possibility? Clinical presentation sounds like pid with lower abdo pain but not acutely unwell with abscess or florid sepsis
Sujoy Dasgupta ( India) Pregnancy related 2 possibilities are there- 1) Spectic abortion, as suspected- there might be some instrumentation of the uterus (probably done by unauthorized persons) leading to infections (and thus PID/ Tuboovarian mass/ abscess) and also renal failure as a sequale of sepsis. 2) Relatively unlikely pathology- Chronic ectopic pregncncy- mimicking ovarian mass, that probably underwent infective changes due to some infection (whatever be the source (may be sexually transmitted) or coexistent PID (in chronic ectopic, urine beta hCG may be negative).... But in that case, renal cast is somehow uncommon and probably there may be coexisting renal pathology also.... Now, she needs stabilization from medical point of view- especially controlling hypertension, anaemia and renal parameters. Then definite therapy should be planned. Renal-friendly antibiotics should be started immediately (hope she is receiving those).... Then preferably diagnostic laparoscopy (if fit for GA from anaesthetic point of view) and then proceed accordingly (with counseling that she may need ovarian ''abscess drainage, salpingo-oophorectomy, even hysterectomy consent should be taken). Usually drainage of infective focus leads to dramatic improvement of renal parameters
Prakhar Gupta (Resident in charge, India) the patient is denying any effort to abort the possible pregnancy. All she did was that she took 4 pills (not sure if they were OC pills or iPills) after about a month of intercourse when she suspected pregnancy (probably on missing periods). Her cycle...See More
Prakhar Gupta USG says distorted renal architecture and little reduction in size bilaterally. Adding to it the anemia, we can think of some chronic renal condition which got precipitated by her prolonged NSAID usage for headache and dysmenorrhea.
Kausik Khan Hi Prakhar, loss of corticomedullary differentiation is suggestive of renal oedema secondary to hit noyhing more to be honest
Prakhar Gupta but considering reduction in size and anemia of that grade (6.6 g%) suggests something chronic.
Michele Meltzer (US)This is a very unfortunate case. Does she have an active sediment in the urine to suggest post infectious GN?? I also agree that toxin induced renal damage should be considered. My expertise is not in this area, however.
Kausik Khan Rakesh, what was her inflammatory markers such as CRP? Was it done before? Don't think I have seen it in the results. Common thing happens commonly. So what was the crp? Her initial counts were high (nearly 11 thousands). TO mass,
Kausik Khan Needs to looked at closely. It doesn't sounds like sepsis induced rather post infectious. Sepsis induced isolated organ damage is unlikely it should be multiorgan failure. How abnormal the counts are in post strep glom nephritis? They are normal. I suspect c3-4 crp should be dine.
NSAIDs induced analgesic nephropathy is a rather remote possibility but yes very interesting case. I am learning
NSAIDs induced analgesic nephropathy is a rather remote possibility but yes very interesting case. I am learning
Rakesh Biswas Kausik would be good to have more inputs on how we may link up the Ovarian mass with her ARF/CRF.
Kausik Khan Rakesh, I think we need some more work up. First Complements, and ANA dsDNA etc. Is this t-o mass a granuloma? We need to think infection(granulomatous), auto immune condition if this not related to obs and gynae. So first thing is to ask obg to rule out that it is not related to abortion pid tumour etc.
Prakhar Gupta update: her renal failure seems to be worsening. Urine protein creat ratio has increased from 0.4 (09/02/16) to 2.6 (15/02/16) . Her BP is now persistent at 170/100 mmHg despite medication. WBC counts have increased from 7000 (4 days ago) to 10800 (today). urine RM report says ++++ albuminuria,
5-6 pus cells, 5-6 RBCs and few casts.
5-6 pus cells, 5-6 RBCs and few casts.
Sujoy Dasgupta Ovarian mass can only lead to renal failure (usually ARF) either by causing severe ascites and thus hypoproteinaemia (which is not there) or ureteric obstruction (but that must be bilateral and should be identified by USG)
Bhavik Shah (Gujrat, India) Yes, this is interesting.
But rather than writing this one, I'm more amused with this clinical dilemma. I think we just need answers to these questions:
1) Are these three conditions interrelated and consequential: taking pills, tubo-ovarian mass and renal failure?
2) If not, what's causing them individually!
But rather than writing this one, I'm more amused with this clinical dilemma. I think we just need answers to these questions:
1) Are these three conditions interrelated and consequential: taking pills, tubo-ovarian mass and renal failure?
2) If not, what's causing them individually!
Ashwani K Gupta (US) What kind of casts are in the urine. Do we have serologies like Ana and complement levels. Why not do a kidney biopsy
Deepika Agrawal Urine shows granular cast. renal biopsy is on plan but first we wanted to get clear with this ovarian mass(may be the reason of her ARF),planning for laproscopy .
Ashwani K Gupta Stick a needle in the kidney while you are in there. Most likely this is atn that will recover.
Local conversational clinical decision support:
Rakesh Biswas She has features in her urine RM suggesting acute glomerulonephritis. Can anyone suggest possible etiologies for this?
Rakesh Biswas Her hypernatremia could be due to post-acute renal failure diuresis in the face of inability to maximally concentrate the urine because of renal failure. The diuresis may cause a disproportionate loss of water in excess of that of sodium in the absence of replenishment of the water loss.http://www.ncbi.nlm.nih.gov/pubmed/21947735 So Dr Arun and Dr Prakhar it would be important to know her urine output.
Rakesh Biswas Dr Prakhar, Deepika plan her renal biopsy with Dr Agamya for day after tomorrow. Get PT-INR, CBC and viral markers prior to biopsy. Also get urine for protein creatinine ratio.
Prakhar Gupta all done today sir. Reports will be available by tomorrow. And tomorrow we'll talk to dialysis ppl as well as Dr. Agamya sir. We need to act fast on this girl before she deteriorates sir.
Rakesh Biswas Let us hope she doesn't have to go for dialysis. Do you spot any indicators currently for dialysis in this patient?http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387587/
Rakesh Biswas See if she has any absolute indications from this list here:http://cjasn.asnjournals.org/.../3/3/876/T1.expansion.html
Prakhar Gupta Arun, it will be great if you can look at her file and tell us her recent Haemoglobin and other blood counts.
Prakhar Gupta ask nurse about her today's reports. Her haemoglobin and other blood counts. Not the printed ones. And plz check if that girl is awake and her general condition.
Arun Chaudhary Intake of liquid..
Morning- milk..daliya..biscuits with tea..
Evening - papaya...
All day water - 500 ml..
So..500+600=1100ml
Urine output...
1st time- 7 am....-.150 ml
2nd time.- 12 pm..- 150ml
3rd time..- 3 pm...- 150 ml
4th time..- 6 pm..- 150 ml..
Total - 600 ml...
Total output..- 600 ml...
BP- 150/100 mg/hg..
General weakness...
GC- stable
Pulse- 78/min
RR- 20/min
Adv- MRI ...abdomen+pelvis
CBC..
RFT
Serum KT
Treatment- tab. Amlodipine 5 mg
Tab. Lasix..40 mg
Tab. Arkamine 0.1mg
Tab. Iron + folic acid
Tab. Shalcal 500 mg
Tab. Pantop 40 mg
Inj. Emiset 4 mg
Morning- milk..daliya..biscuits with tea..
Evening - papaya...
All day water - 500 ml..
So..500+600=1100ml
Urine output...
1st time- 7 am....-.150 ml
2nd time.- 12 pm..- 150ml
3rd time..- 3 pm...- 150 ml
4th time..- 6 pm..- 150 ml..
Total - 600 ml...
Total output..- 600 ml...
BP- 150/100 mg/hg..
General weakness...
GC- stable
Pulse- 78/min
RR- 20/min
Adv- MRI ...abdomen+pelvis
CBC..
RFT
Serum KT
Treatment- tab. Amlodipine 5 mg
Tab. Lasix..40 mg
Tab. Arkamine 0.1mg
Tab. Iron + folic acid
Tab. Shalcal 500 mg
Tab. Pantop 40 mg
Inj. Emiset 4 mg
Prakhar Gupta thanks dost. But reports kal wale hain blood ke.. Latest ek slip pe haath se likhe the sister ne..
Arun Chaudhary Night urine output ....
7 am....100 ml
Stool- OK
Intake of water in night - approx 80 ml
7 am....100 ml
Stool- OK
Intake of water in night - approx 80 ml
Rakesh Biswas Prakhar has her urine output come down!! Dr Arun please let us know what was her total urine output yesterday.
Rakesh Biswas Her MRI is fixed with Dr Aastha for tomorrow. Dr Jyoti please follow up. Did we meet the dialysis team today?
Prakhar Gupta yes sir, i talked to dialysis people. They said they can do dialysis at night but first we need to have her canula in place which can be done by Dr. Upadhyay sir. And canula can be fitted if thrs actually need of dialysis. So we need to weigh risks n benefits for her in this respect.
Prakhar Gupta astha mam did USG again but she didn't (or couldn't?) obtain consent for TVS.. And she said MRI will tell her condition btr..
Arun Chaudhary Morning to evening intake of fluid -
500 ml water ...+ 50 ml tea + 150 ml milk .. = 700ml...See More
500 ml water ...+ 50 ml tea + 150 ml milk .. = 700ml...See More
Rakesh Biswas Prakhar, Deepika we just reviewed her MRI and the images are striking. Please discuss with Aastha, Agamaya asap.
Rakesh Biswas She has a large ovarian mass on the right along with ascites (? hemorrhagic). Please take her down for a USG guided tap with Dr Astha or Dr Agamya. Or just ask them to do an ultrasound and point you to where you can put the needle. Also inform Dr Sirvastava
Prakhar Gupta update: dialysis done this evening.. (phew!) she is stable and asking for food now. BP was 170/100 mm Hg at 8.30 pm and she was then given amlodipine.
Prakhar Gupta one incidental finding while inserting femoral catheter was palpable inguinal lymph nodes.. We might need to further confirm about ovarian mass as positive lymph nodes can suggest a malignant tumour which has spread and causing renal failure..
Rakesh Biswas Lets get an FNAC from the inguinal lymph nodes if you think they are sized significantly
Arun Chaudhary Output n input of 13-02-2016 night
10 pm ...dal rice ..+ water = 70 ml
4 am..dal rice + water = 70ml
14-02-2016 morning..
70 ml water +biscuits..
Total = 210 ml
No any output
10 pm ...dal rice ..+ water = 70 ml
4 am..dal rice + water = 70ml
14-02-2016 morning..
70 ml water +biscuits..
Total = 210 ml
No any output
Rakesh Biswas Thanks Arun, Please mention the dialysis notes here. Update the image of the dialysis notes. How much ultrafiltrate was removed? The output and input should be of the entire day of 13/2/16 and not just yesterday night's. Please mention the entire day's intake output for yesterday.
Rakesh Biswas We shall have to organize the lower abdominal fluid aspiration tomorrow Dr Jyoti, Prakhar, Deepika
Jyoti Tripathi Patient....fair...no complaint.....pain relief...
Urine....1time
Bp_ 150/100
Temperature _98.2
Pulse_ 76
Urine....1time
Bp_ 150/100
Temperature _98.2
Pulse_ 76
Rakesh Biswas This is the collection we need to put a needle into:https://1.bp.blogspot.com/.../s82cJSjC9zU/s1600/17.jpg
Rakesh Biswas Just above the urinary bladder. We need to be careful not to hit the ovarian mass above.
Rakesh Biswas Dr Jyoti can you copy paste this patient's history in this comment thread here (in English or/and HIndi) so that we can add it to the patient's blog here:http://globaludhc07.blogspot.in/.../a-18-years-old-girl...and then share it in tabula-rasa?
Prakhar Gupta update: her renal failure seems to be worsening. Urine protein creat ratio has increased from 0.4 (09/02/16) to 2.6 (15/02/16) . Her BP is now persistent at 170/100 mmHg despite medication. WBC counts have increased from 7000 (4 days ago) to 10800 (today)
Prakhar Gupta have increased amlodipine to 5 mg in the morning and 10mg at night. Lasix total 60mg in divided doses.
Rakesh Biswas This is not very alarming but we need to look at her urinary sediment and get another urine RM positively tomorrow.
Rakesh Biswas We needed to have aspirated her collection today. What did the sonologist say Dr Jyoti?
Rakesh Biswas DrJitendra please provide the update here. Do not use the patient's name to protect her privacy.
Rakesh Biswas Yes Prakhar has already informed 3 hours back about what you mentioned but please let me know her current pulse rate and Bp and her symptoms.
Arun Chaudhary BP- 150/100 ...10:30 pm
Increase BP - tachycardia
ECG- ventricular adoptes HR - 115
Adv- BP/Hour
RFT- urea - 189 ...createnine - 14.9
Patient is normal
Output of patient - 4 time urine
8 am - 150 ml
1 pm - 150 ml
4 pm - 150 ml
9 pm - 150 ml
Total - 600 ml
Total intake of day - 750 ml water
.amelioration after urine ..
Sodium /serum - repeat
Urea /createnin ...repeat
Increase BP - tachycardia
ECG- ventricular adoptes HR - 115
Adv- BP/Hour
RFT- urea - 189 ...createnine - 14.9
Patient is normal
Output of patient - 4 time urine
8 am - 150 ml
1 pm - 150 ml
4 pm - 150 ml
9 pm - 150 ml
Total - 600 ml
Total intake of day - 750 ml water
.amelioration after urine ..
Sodium /serum - repeat
Urea /createnin ...repeat
Prakhar Gupta Her tachycardia is still there and BP got high again. She also had palpitations..ANd looking at her creatinine.. I think we need dialysis. Deepika is there in the hospital, she is arranging for dialysis.
Deepika Agrawal Her bp is maintained at 140/90 since last night tachycardic raised jvp,subjectively patient doenot complain of anything except pain in lower limbs. Planning for dialysis and 2d-echo(to look for pericardial effusion or pericarditis) tomorrow (discussed with dr . Upadhyay )
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