CASE PRESENTATIONPresentor:Le Thi Ngoc SuongFriday, July 27, 2012

42 VNMCC: vomittingAdmission day : 2 JulyHPI: Onset: 4 daysDay 1: epigastric pain vomit abdominal pain diarrhea

Day 2,3: oliguria, ~ 200 ml/day edema, 2 legs Jaundice abdominal pain vomit, 6-7 times/day diarrhea, 4-5 times/day loss appetite Use unknown drugs from the drug store, no alleviation

Day 4: feel exhausted from vomitingAdmit to Long An hospital (in 11 hours) CR hospitalAllergies: NKDAMedication: nonePSH: nonePMH: noneSH: SMKFH: none

On admission:VS: P 70, t 37, BP 160/100, RR 24, W 54General apperance:AAO x3 Light edema, 2 legs P 70, t 37, BP 160/100, RR 24, W 24

Lung sounds: no crackes.CVS: no JVD, S1, S2, RRRAb: WNL

Transfer paper: AO x3, P: 100, BP: 160/80; Heart, Lung, Ab: WNLAnuria/ 11 hours of hospitalizationCre: 960mcmol/l (10.84 mg/dL), Na 127, K 3.5 mmol/l, AST 162, ALT 1687 U/L, ABG: pH 7.3, PaCO2 27, PaO2 109, HCO3 15mmol/lDiagnosis: Acute renal injuryTreatment: NaCl 0.9% 500 ml

1. What do you want to ask and find more on admission?2. What is your diagnosis on admission?3. What do you want to do next?

History:FoodThirst, orthostatic dizziness

Physical examination:Orthostatic hypotension, volume depletion (decreased skin turgor, dry mucous membrane), reduced jugular venous pressure

Diagnosis:History: oliguria Acute Kidney Injury Causes:

Differential diagnosis:1. Intrinsic AKI- oliguric period, day 4- acute tubular necrosis caused by carp fish bile poisoning.2. Intrinsic AKI- oliguric period, day 4- acute tubular necrosis caused by renal ischemia.3. Prerenal AKI- oliguric period, day 4- hypovolemia

Laboratory tests suggestion:UrinalysisB.U.N, Serum Creatinine, Creatinine phosphokinase.Blood electrolytesFENa, urine specific gravity, urine osmolarity, urine-to-plasma urea ratio Ab Ultrasound

1. What is your diagnosis at that time?2. What do your treatment for this patient?

Diagnosis:Acute kidney injury.Oliguric period, dayAcute tubular necrosis:B.U.N/ cre1%, Na/Urine>40Hydrostatic urine Pressure

Plan:Drugs to stop vomiting, diarrhea.Antihypertensive drugs.HemodialysisNutrient support

Indications of dialysis:symptoms or signs of the uremic syndrome management of refractory hypervolemia, hyperkalemia, or acidosis.Oliguria or anuria.BUN>100 mg/ml, serum creatinine 8-10 mg/dLIntoxication

Treatment:Omez SmectaEnterogerminaCarbophosAmlor 5mg Hemodialysis

3 July: ( dialysis :2 July)AAO x3.BP (lying): 160/100 mmHgBP( sitting): 130/90 mm HgStop vomiting, no abdominal pain.Diarrhea, watery stool: 4-5 times/day.Lung: no crackesCVS: Ab: WNL

2/73/74/75/79/710/711/712/713/716/7B.U.N81 mg/dl6375534546525239Creatine/Blood9.3mg/dl8.9110.227.568.16378.198.126.433.83eGFR6.64 mL/min/1.73 m2 6.985.968.447.737.717.697.7710.1718.49Na/ blood126mmol/l1281271281288.35132138139K/blood4.6mmol/l3.13.42.831372.94.03.4Ca/Blood2.3mmol/l1.92.12.52.32.22.01.92.1Blood osmotic pressure289 mmol/kgCreatinin/ urine2047.9Urine osmotic pressure265Na/urine116.744K/urine10.97.1Ca/urine1.260.3Ure/urine2.14

Questions:1/ Low serum sodium?2/ No hyperpotassium?3/ High ALT?4/ High serum amylase?

Discharge :17/7 (day 18):Diagnosis: AKI caused by fish bile poisoning- hypertension- follow up with the chronic pancreatitis.

Thank you for joining