Staff round presentation

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Staff round presentation

• Prof.Dr. Gamal Esmat
• -Ass Prof.Hasan El Garem -Ass prof.Maissa El
  Razky
• -Dr.Mohamed Ibrahim -Dr.Ahmed Foad
• -Dr.Wafaa Elakel
• -Ass Lecture.Yasmin Saad -Ass Lecture. Dina
  Ismail
• -Dr. Mohamed Hamed -Dr. Mohamed Abdel
  hafez

• By
• Resident.Ahmed Khairy

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Personal History

• Admission 5/8/2005
• Male patient .
• 55 yrs old.
• Married 35 yrs ago with 4 offsprings, youngest
  16 yrs old .
• Works as a farmer.
• Born and living at Manwat Giza.
• History of contact with canal water and received
  anti-schistosomal ttt in the form of injection
  and tablets.

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Complaint
Pain in the Lt upper quadrant of the abdomen of
3 months duration (May 2005)
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Present history

• Started 3 months before admission by
• Lt hypochondrium dull aching pain, not
  radiating or referred, with no special
  precipitating or relieving factor.
• Recurrent attacks of bilateral loin colicky pain
  radiating to the groin with no special
  precipitating or relieving factor.
• Weight loss.

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• No fever, loss of appetite or night sweats.
• No body masses or bony pains.
• No history of jaundice, ascites, LL edema,
  hematemsis, melena, bleeding tendency or
  disturbed conscious level.
• No history of recurrent infections.
• No history of palpitation, dyspnea, dizziness or
  blurring of vision .
• No history of travelling abroad.
• No dysuria or frequency of micturition.

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• Past history
• - No DM - No hypertension
• - No previous operations.
• - No previous blood transfusion
• - No history of drugs intake
• Family history
• No similar conditions

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General examination

• The patient is conscious, of average
  intelligence, well oriented to time, place and
  person, lying comfortably flat in bed.
• BMI63 / 1.752 20.5
• Pulse 80/min, regular, average volume, no
  special character, equal on both sides.
• Bp 110 /70
• Temp 37.2 (on admission)

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Temperature chart
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Head Neck

• Pallor
• No jaundice or cyanosis
• Cervical lymph nodes not palpable
• Neck veins not congested
• Thyroid gland not enlarged
• Trachea central
• UL LL
• Inguinal LNs
• Two enlarged LNs (0.5-1 cm) on each side, firm,
  discrete, not tender
• No palmar erythema, clubbing or LL edema
• CVS Chest Free

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Abdominal examination

• Liver
• upper border 5th space right MCL.
• lower border
• Rt lobe not felt.
• Lt lobe 2 fingers by light
  percussion
• Spleen enlarged 10 cms below Lt costal margin,
  firm in consistancy, smooth surface, rounded
  anterior border, preserved notch .
• Kidneys not felt
• No ascites detected by shifting dullness

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Summary

• Left hypochondrial pain
• Bilateral loin pain
• Weight loss
• Huge Splenomegaly and pallor

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Investigations
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On admission

• Renal function tests
• - Creatinine 5.4 - urea 120
• - Abdominal US
• Bilateral parenchymal renal disease with back
  pressure changes and multiple stones.
• Right upper hydroureter.
• Left renal cyst.
• - Plain UTI stone in lower right ureter
  and multiple left renal stones.
• Double J catheter was inserted in the right
  ureter.
• Follow up
• - Creatinine 1.1 ( over 5 weeks duration)
• - US resolved back pressure changes
• But the patient develops attacks of fever and
  dysuria

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• 24 hrs urinary proteins 0.8 gm (Nlt0.15 gm )
• Culture sensitivityPseudomonas aeruginosa
• Stool analysis Free
• Occult blood in stool negative

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CBC
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• Ferritin 345.00 ng/ml (N 28
  -397)
• Serum Iron 16 ug/dl (N 70
  -170)
• TIBC 192 ug/dl (N
  250 -380)
• Reticulocytes 1.9 (N
  0.2-2)

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Liver biochemical profile

• AST 8
  (N0 41)
• ALT 11
  (N0 41)
• Bilirubin ( total ) 0.37
  (N0.2 1.2)
• Alkaline phosphatase 75 (N40
  150)
• Total proteins 5.4
  (N6.4 8.3)
• Albumin 2.8
  (N3.5 5)
• LDH 245 U/L
  (N125 243)

• PC 72
• INR 1.32

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Protein electrophoresis

• Total protein 5.0 g/dl
• A/G 1.46
• Albumin 2.8 g/dl
  (N 3.5 5)
• Alpha 1 0.2 g/dl
  (N 1- 0.35)
• Alpha 2 0.6 g/dl
  (N 0.65 -1.2)
• Beta 0.6 g/dl
  (N 0.74 -1.26)
• Gamma 0.7 g/dl
  (N 0.6 -1.7)
• There is decrease in serum total protein
  albumin
• There is mild decrease in B-globulins

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Kidney function tests
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Na
139 K
3.7 Fasting blood sugar
98 2Hr pp blood sugar
129
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Abdominal Ultrasound (7-8-2005)
-Liver Average size, bright echopattern,
smooth surface and normal hepatic veins. A small
hypoechoic focal lesion in segment V (mostly fat
sparing area). No IHBR dilatation P.V. is not
dilated. -Spleen Markedly enlarged (longest
axis is 24 cm) homogenous. Kidneys Average
size, grade I parenchymal echogenicity, Right
kidney shows moderate back pressure moderate
upper hydroureter with multiple stones. Left
kidney shows multiple stones with minimal back
pressure . A cyst in the upper pole measuring 4
cm.
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-Gall bladder Average size and wall thickness,
no stones or mud inside. CBD is not
dilated. Conclusion -Bright liver with? Fat
sparing area. -Huge
splenomegaly. -Bilateral parenchymal renal
disease with back pressure and multiple
stones. -Right upper hydroureter
-Left renal cyst.  
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Abdominal Ultrasound(4-9-2005)

• -Liver Average size, bright echopattern, smooth
  surface and normal hepatic veins. There is a
  hypoechoic focal lesion in segment v (mostly fat
  sparing area). No focal lesions or IHBR
  dilatation P.V. is not dilated.
• -Gall bladder Average size and wall thickness,
  no stones or mud inside. CBD is not dilated.
• -Spleen Hugely enlarged (longest axis is 24 cm)
  homogenous echopattern.
• - The left kidney shows two stones in mid and
  lower poles a small cyst 1.6 cm in diameter. No
  backpressure changes.

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-Pancreas free. -No ascites. Conclusion -
Bright liver with? Fat sparing area. -Huge
splenomegaly. -Left renal cyst.
-Left renal stones.
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Hepatitis markers
Tumor markers

• B2Microglobulin(serum) 9693.1 ug/L (N
  -1150)
• CEA 1.4
  (N
• AFP 2.23
  (N
• CA19.9 0
  (N

• HBsAb -ve
• HbsAg -ve
• HCV antibody 3rd generation -ve

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Causes of increased b2 microglobulin

• 1-Glomerular renal diseases.
• 2-Multiple myloma.
• 3-Caner.
• 4-Collagen disorders.

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Post contrast CT abdomen pelvis
- Liver Average size showing homogenous
parenchymal texture with wavy outline. No focal
hepatic lesion or IHBRD. - Patent homogenously
enhancing main portal vein . - Huge splenomegaly
of uniform texture. Kidney - Left kidney showed
upper polar simple cortical cyst. - Right sided
double J ureteric catheter seen in
place. Fullness of the right pelvicalyceal
system. -  Mild prostatic enlargement. -  No
abdomen and pelvic lymphadenopathy. Opinion Huge
splenomegaly for clinical laboratory
correlation.
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Skeletal survey ( 1/10)

• X-ray of the skull (lateral view), right elbow
  wrist, pelvis right femur revealed
• No significant abnormalities detected.
• X-Chest x-ray (PA view) reveled
• Prominent pulmonary interstitial markings
  .Bilateral (mainly right sided) basal
  accentuation of bronchovascular markings with
  bronchial peribronchial thickening linear
  atelectatic bands. Suspected left basal patch of
  pneumonitis. Clear both lateral C/P angles.
  Normal cardio-thoracic ratio.Prominent hilar
  vascular shadows.

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• X-ray of the LSS revealed
• Mild spondylolisthesis of L4 over L5.
• Spondylodegenerative changes (more pronounced at
  L4-5 L5-S1 levels).
• Narrowed L4-5 disc space.
• A right sided double J catheter is seen
• Left renal region dense shadow is seen (?
  Calcular) for US correlation.
•  

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Bone marrow aspirate ( 2/10 )

• Normocellular BM.
• Myeloid show shift to Lt some of them show
  hypopigmention.
• Erythroid show errythroid hyperplasia.
• Megas are normal in number with normal
  granulation lobulation plt budding.
• BM platlet are normal.
• Blast 1
  B 0 E2
  
  
  Premyelocytes 10
  Juveniles 8
  
  Stab neutro 14
  Seg. 3
• Conclusion
• Normocellular bone marrow with erythroid
  hyperplasia

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Splenic aspirate ( 5/10 )

• Microscopic examination
• Cytological examination of smears cell block
  revealed
• Many RBCs with hollow centers indicating severe
  hypochromic anemia.
• Pleomorphic lymphoid population consisting of
  many mature immature lymphocytes as
  immunoblasts and lymphoblasts were also seen.
• Diagnosis
• Benign smears
• No evidence of lymphoma/
  leukemia.

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Follow up CBC

• ( 8/10 )
• - RBCs 2.9
• HB 7.1 MCV 76.5 MCH 76.5 MCHC
  31.5
• - WBCs 1.8
• PTL 276
• (12/10 )
• - RBCs 2.5
• HB 6.3 MCV 75.6 MCH 24.3 MCHC 32.2
• WBCs 1.1
• Lymph 70
  
• Mono 14
• Blasts 16
• PTL 178

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Bone marrow biopsy

• Examination of serial sections reveled
• Hypercellular bone marrow with multifocal
  lymphoid infiltrate, inter paratrabecular, with
  some are mature some arent mature.
• Other haematopoietic tissues are markedly
  depressed.
• Megarkaryocytic series is preserved.
• Patchy areas of 2ry bone marrow fibrosis
• Conclusion
• Leukemia phase of lymphoma IV

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Upper GIT endoscopy

• Oesophagus shows scattered whitish patches
• Monilial esophagitis.
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Lower GIT endoscopy

• Early internal piles only.

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