case 3. نرگس حجازی 5 ساله با شرح حال تشنج فوکال که از 7 روز...
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CASE 3
حجازی نرگس5 از که فوکال تشنج حال شرح با قبل 7ساله روز
است کرده مصرف .فنوباربیتالCc: از اریتماتوز 2تب پاپولر ماکولو راش و قبل روز
T=39
• LAB:• WBC:7.1 3.7• HB: 11.9 12.2• PLT: 159 132 100• EOS: 3% 1%• ESR: 15 35• CRP:3+• UC(-)• BC(-)• AST: 444 72• ALT: 394 227• ALP: 461
• PLAN • کلونازپام شروع و فنوباربیتال قطع
• از پس تب روز4قطع• از پس راشها روز2بهبود
DX
• DRESS S.
• FOLLOW UP• تب ادامه عدم• WBC:6.9• HB:12.8• PLT:376• EOS:3.4• ESR”23 CRP:NEG• ALT:14• AST:45• ALP:374
Case 4
5 month girl Cc:FTT History of 2 hospitalization for pneuminia and
FTT Bw:2700 Nw:4.5
• LAB:• Wbc 16.4 ph:7.5• Hb:9 co2:29• Plt:318 Hco3:24.6• Ur:10 SE:NL• Cr:0.3 AST:102 ALT54 ALP590• Na:134• K:3.4
• CXR: infiltration• Other lab NL• PLAN:• Ab therapy• Sweat test:• cl=65• na=55
DX
• CYSTIC FIBROSIS
• PLAN:SWEAT TEST
In the name of GOD
CASE 1
• ID: AmirHossein Rahmani• CC: Weakness • PI: A 10yrs old male presented with nausea
and headache from 1 days ago followed by walking disability and weakness. He had a history of paresthesia in distal parts of the limbs from 1 month later.
PMH
• Without a significant abnormality
Physical Examination
• Normal vital sign• Normal general examination• Normal cranial nerves• Normal sensory system• Normal DTR• Force of lower limbs• Flexor plantar reflex
Laboratory Data
• BS: 141• Urea: 36• Cr: 0.7• Na: 137• K: 4.5• Ca: 10.1• WBC: 11700 Neut: 80/ Lym: 12• RBC: 4.4 Hb: 12.6 Hct: 36.4• Plt: 323000• CPK: 248
• EEG– Showed sharp waves at occipitotemboral lobe
• Brain CT Scan: – Normal
Psychiatric consult: Conversion Disorder
Final diagnosis
Conversion disorder
CASE: 2
• ID: Saleheh Golmakani• CC: Weakness and gait disorder• PI: A 8 yrs old female presented with flue- like
syndrome from 4 days ago followed by low back pain and walking disability.
PMH
• No significant abnormality
Physical Examination
• Normal vital sign• Normal general examination• Normal cranial nerves• Sensory level at thoracolumbar area• Decrease muscular force at lower limbs• DTR of lower limbs• Plantar reflex: Babinski
Laboratory Data
• BS: 81• Urea: 40• Cr: 0.5• K: 4.2• Ca: 10.1• Mg: 2.3• U/A: Nl• RBC: 4.5/ Hb:13.5/ Hct: 39.4/ MCV: 85.8• WBC: 7700(neut: 72, lym: 20)• CSF:
• sugar: 79/ pr: 19/ LDH: 26/ chol: 0• WBC: 47 (neut:80, lym: 20)/ RBC: 0
others
• Anti- HIV: neg• Anti- HTLV1: neg• Anti ds DNA: 21• C3: 175• C4: 35• ANA: 9• RF: neg• B/C: neg• U/C: neg• CSF/C: neg
• SSEPS:– Nl
• MRI: – hyperintensity of right temporoparietal lobe and
medula at T2
Final diagnosis
Demyelinating disorder probably MS
Case Report
CASE 1
An 6 m old infant came with CC of FTT + Cough
Lab Results
• VBG: Ph =7.30• PCO2 = 13.7• HCO3 = 7.7• Urea : 19 _ Cr : 0.5• U/A : Ph = 6• U/C : Neg• B/C : Neg
Radiology
• Plenty of stones with the size of 0.5 _ 1.5mm in calises in both kidneys and nephrocalcinosis
Diagnosis
• Renal Tubular Acidosis type I (RTA I)
PrimaryIdiopathic , sporadic
FamilialAutosomal dominant
Autosomal rersessive
SecondarySjogren syndrome
Hypercalciuria
Hyperglobulinemia
Ifosfamide
Cirrhosis
Systemic lupus erythematosus (may be hypercalemic)
Sickle cell anemia ( may be hypercalemic)
Lithium carbonate
Rheumatioid arthritis
Obstructive uopathy
Renal transplantation
Diagnosis
• Type I RTA is presented with normal AG(hyperchloremic metabolic acidosis) metabolic compensation for respiratory alkalosis produces an electrolyte pattern that is identical to that seen in a normal AG acidosis thus the first step in the diagnosis of the patient with the reduced serum bicarbonate and elevated chloride concentration is to confirm that metabolic acidosis is present by measuring the blood Ph
Urine Ph
• Patient with normal renal function and normal renal acidification mechanism would develop metabolic acidosis usually have a urine Ph of 5.3 or less as ammonia (NH3) defuses into the tubular lumen it mostly combines with hydrogen ions to form ammonium (NH4+) the reduction in the free hydrogen ion concentration elevates the urine Ph depending upon the chronicity of the acidosis and the degree of hypokalemia the urine Ph may be 5.5 or higher .
• In most cases of distal RTA the urine Ph is persistently 5.5 or higher
Treatment
• The correction of the metabolic acidosis results is restoration of normal growth rates in children and also has the following benefits:
• Minimizing new stone formation and nephrocalcinosis .
• Demolishing calcium losses induced by bone buffering of some of the return acid .
• The aim of alkali therapy is to achieve a relatively normal serum bicarbonate concentration (22 to 24 meq/lit)
• Children may require as much as 4_8 meq/kg/day in divided doses because they often have a higher fix urine Ph as a result fixed bicarbonate losses are frequently higher than in adults .
• Potassium citrate alone or with sodium citrate (polycitrate) is indicated in patient with persistent hypokalemia or calcium stone disease but not in patients with the hyperKalemic form of distal RTA
CASE 2
• A 3.5 year old boy with the history of 2 times complex seizure in the last month and under the treatment with Phenobarbital which happened to appear with fever , rash and conjuctivitis and didn’t respond to antibiotic therapy
Lab Results• WBC=4.1 3.9 3.4 9.5 3.8
• Hb = 9.1 10.5 9.1 9.2 8.1
• Plt = 128 191 434 690 544
• ESR = 12 70 101
• CRP = 3+ 2+ 3+
• U/A : NL• U/C : Neg• B/C : Neg• AST = 131 41• ALT = 134 65• ALP = 649
• Echocardiography : NL
Diagnostic criterias of Kawasaki disease
Laboratory criterias
Algorithm