Case follow up

After 6 sessions of hemodialysis and supportive care, the patient started to urinate about 3-4 liters per day (which was consistent with polyuric phase of ATN). Exessive hydration was prescribed.
Three days after antibiotics administration, he became afebrile and WBC count started to rise.

At the time of discharge he was well oriented and alert.
Urine output was about 2 liters per day. His final lab tests:
Cr 1.1
Urea 67
K 3.8
P 4.4
Ca 9.4
Uric acid 5.4
WBC 5.6
Hb 9.9
Plt 215000

He was then discharged and referred to the hematology clinic.
End of case 27

Case number 28
A 33 y/o confused man was brought to the emergency ward by EMS. He does not answer your questions and just moans and complaints about headache.
Initial vital signs:
BP 130/80
PR 100
RR 24
T 37.8
Weight 80 kg
BS 100

Pupils were midsize and reactive to light
No focal neurological deficit was detected at the beginning.
Fundoscopy showed no significant pathology.

While searching the patient's pockets for any evidence and identity cards, you find a badge with the label "hemophilia A".

In hemophilia A patients with suspected severe or life-threatening bleeding it is important to "Treat first, evaluate second, plan further therapy third"
For potentially serious or life-threatening bleeding, give factor before imaging or other evaluations.
Initial examination findings may be subtle or absent; treat based on the medical history.
If a diagnostic procedure is required (lumbar puncture, arterial blood gas, arthrocentesis), give factor to raise the level to 100% before performing the procedure.
If the patient requires transfer to another facility, give factor before (or during) transport.
For severe disease, assume the factor level is 0%.
Do not waste factor (administer excess rather than discarding).
Use an indwelling central catheter to administer factor if present. If not, the most experienced individuals should perform venipunctures and place an intravenous line if needed. Traumatic venipunctures can cause painful hematomas that limit intravenous access.

The treatment of choice in hemophilia A patients is the patient's own factor VIII product or recombinant human factor VIII. If neither is available, give plasma-derived factor VIII.
For severe bleeding in patients without an inhibitor, give factor VIII at 40 to 50 units/kg as soon as possible to produce a factor VIII level of 80 to 100%.

For less-severe joint or muscle bleeding, a target factor VIII level of 40 to 50% may be used, by giving factor VIII at a dose of 20 to 25 units/kg.
For severe bleeding in patients with an inhibitor, a bypassing product may be indicated (rFVIIa or FEIBA).

For individuals with mild hemophilia A (baseline factor VIII 5 to 50%) who have a documented response to DDAVP and non-life-threatening (or non-limb-threatening) bleeding, DDAVP may be used.

A few moments later the monitor showed blood pressure rise to 200/120. The patient became dyspneic. The ECG is shown in the picture.

Case number 29
A 50 y/o man came to the emergency ward with the chief complaint of low back pain. The pain started 2 months ago and suddenly exacerbated 3 days prior to his admission.
He described it very severe and can not even change his position due to severe pain.
He mentioned significant weight loss and episodic fever and chills.

His vital signs at the beginning
BP 130/80
PR 100/min
SPO2 90%
T 37.3

On physical examination, there was significant point tenderness in L1-L3 vertebrae. No other skin or muscle abnormalities were detected. Lower extremities forces were intact without any weakness.
Suddenly one of the students noticed an abnormal bulging near the manubrium of the sternum which was warm and had erythema and also tender.

Case follow up
Coincident with our presumption, Methicillin Resistant Staphylococcus Aureus grew up in sternoclavicular synovial fluid. Vancomycin was started as soon as possible.
Regarding the patient's dyspnea and hypoxia, chest CT scan was done which showed bilateral nodules and round masses and bilateral multilobar pleural based lesions.

Urine analysis:
SG 1025
WBC 0-1
RBC many
Bacteria few
Ep cell 1-2
Protein 3+
Nitrite negative

Transthoracic echocardiogram showed no significant vegetation or other abnormalities. Blood culture was also positive for Methicillin Resistant Staphylococcus Aureus. The picture shows the patient's nail.