Case presentation

ID : 151120064
Name : Hamoud Ghanem Ahmed
Patiant File No: 00320296
History
 Demographic data

Name : X
Age: 41 years old
Sex: Female
Nationality: Saudi
Living in Ryiadh
Marital status : Married
 Chief Complain

Patient came to clinic due to bone and muscle pain since 6 months
History of presenting illness

The pain started at her shoulders then went to her knees , was sudden
and dull , intermittent , the severity of the pain was 9 out of 10
the pain decreased with paracetamol and increased with movement and
associated with body weakness and body itching and weight loss 10 kg
. over 6 months, no fever ,night sweating or loss of appetite
 Past medical History

+ Chronic renal failure

+ Hypertension
No DM
No heart disease
No Asthma
No blood disease
No thyroid disease
No blood transfusion
 Past surgical History

Corneal transplant on the left eye -1

Submandibular gland excision -2
No truma -3
 Family History and Drug History

: Family History
Her father has HNT , DM
No similar disease in her Family

: Drug History
Amlodipine 5mg
Folic acid 5mg
No allergy to food or drug
Social History

non smoker -1
non alcoholic -2
non drug abuse -3
 Review of Systems

GI : lower abdominal pain and constipation -1

Urinary : Unremarkable -2
Respiratory : Unremarkable -3
CVS : Unremarkable -4
Neurology : Unremarkable-5
Gynecology : Unremarkable -6
Skin : Itching -7
 Physical Examination

General exam : the patient was oriented ,conscious , alert not pale or not connected to ventilator mech , and
lying comfortable
: Vital signs
BP :173/79mm/Hg
RR : 20 /minute
’Tem : 36.7 C
HR : 93/ min
SpO2 : 98%
Pulse : 75 BPM
Height : 150 cm
Weight : 55 kg
BMI : 24.4
 Systemic examination

: Neck
Inspection : There are no swellings on the neck
no discoloration of the skin
no obvious tracheal deviation
Palpation : no cervical lymph nodes enlagement , no
sweeling over the thyroid gland , no tracheal deviation
auscultation- no bruit
: Breast
Inspection : Symmetry in size , no swelling , no nipple retraction or
. skin discoloration
Palpation : no mass , no local raise in temp , no tenderness no axillary
lymph nodes enlargement
Abdomen : Inspection : abdomen- non distended
Umbilicus- inverted , centrally placed and there are no scars
.Palpation : Soft , tenderness on suprapubic and left iliac
No rebound tenderness. No organomegaly
Percussion : dullness and auscultation- no bruit
: Urinary system
..Costovertebral tenderness -1
: Respiratory system
Symmetry lung raising and lung expension
Bilateral air entery
, No Crepitation
No wheezing
CVS : No DJV No heart thrill or added sounds
: MSK
Inspection : deformity over fingers of right hand
Palpation : no tenderness , no crepitus , no local raise in temperature
SLR -ve
ROM- possible
Neurologic : unremarkable
: Skin
Inspection : multiple swellings on the posterior aspect of arm and mid-forearm
which asymmetrical , have different shapes and regular, no discoloration or
.edema in surrounding tissue
Palpation : smooth surface , soft , hot and thrill and the average size is 2-3 cm
and pulsatile expansile swellings
+ Auscultation : bruit
AV malformation
 Investigation
: laboratory -1
CBC : low RBCS , MCV : 90 fl and MCH : 30 pg
high serum creatinine and urea
high Serum Ca
high Serum PTH
high Serum phosphorus
Low Urine Ca
Low Vitamin D
:Radiology-2
CXR
DEXA
Ultrasound : 1- Venous Doppler scan UE
. Other : sestamibi parathyroid scan
Differential Diagnosis ?

1- Malignancy
2- Familial hypercalciuric hypercalcemia
3- Primary hyperparathyroidism
4- Lung disease
 Diagnosis

End stage kidney disease with secondary

hyperparathyroidism
) Renal osteodystrophy (
 Management
: Medical
Sevelamer oral 800mg twice a day -1
Folic acid oral 5 mg ones a day -2
Omeprazole oral capsule 20 mg ones a day -3
Cinacalcet oral 30 mg three times a day-4
Chlorpheniramine oral 4 mg-5
amlodipine oral 5 mg twice -6
erythropoietin therapy-7
dialysis -8
: Surgery
Kidney transplant
 : Summary

X is 41 years old female Saudi living in Ryiadh known case of CKD and controlled HNT came
to clinic due to bone and muscle pain since 6 months , started at her shoulders then her knees
was sudden and severe and associated weight loss about 10 kg over 6 months, on physical
eximnation showed she had multi AV malformations on the right upper limb and lab
investigations and imaging showed had secondary hyperparathyroidism due to CKD