Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Neelja Kumar, MD
PGY 3
October 20, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
•54 year old African American man presenting
with left sided testicular pain for one week
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The pain began one week prior to
presentation, associated with testicular swelling
and tenderness
•The pain did not improve with over the counter
medications so he presented to the emergency
department
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•none
•Past Surgical History:
•none
•Social History:
•20 pack-year smoking history, denies alcohol or drug use
•Worked as a college professor
•Family History:
•none
•Allergies:
•No Known Drug Allergies
•Medications:
•None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: healthy appearing, in no distress
•Vital Signs: T: 98.3 BP: 226/121 HR: 78
RR: 14 O2 Sat: 99% on room air
• Left testicular tenderness to palpation
•Trace non pitting edema in lower extremities to
knees bilaterally
• Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: Hemoglobin/Hematocrit: 11/31
•Remainder of CBC was within normal limits
•Basic Metabolic panel: BUN/Creatinine: 36/2.3
•Remainder of basic was within normal limits
•Hepatic panel: within normal limits
•Urine Analysis: coarse granular casts, 3+ protein,
5-10 red blood cells
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•Protein to creatinine ratio 1.7; equivalent to 1.7g per day
•Human Immunodeficiency Virus, Hepatitis B Virus,
Hepatitis C Virus negative
•C3, C4 normal
•ANA negative
•Double Stranded DNA negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Electrocardiogram: normal sinus rhythm
with left ventricular hypertrophy
•Testicular ultrasound: mildly complex
bilateral hydroceles
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Orchitis
• Stage 3 Chronic kidney disease secondary
to hypertensive nephrosclerosis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient was started on ciprofloxacin for
presumed orchitis
– Nicardipine drip initiated for hypertensive
emergency
• Hospital Day 3:
- Kidney ultrasound performed demonstrated
increased cortical echogenicity bilaterally
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 5:
– Testicular pain resolved
• Hospital Day 7:
- Given renal failure and findings on renal
ultrasound, a renal biopsy was performed
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Renal Biopsy
Duplication of elastic lamina
in interlobular artery
Hematoxylin and Eosin Stain:
sclerosis with hyalinosis
Renal Biopsy
Periodic
acid-Schiff
stain:
segmental
sclerosis
and
adhesion to
Bowman’s
capsule
Final Diagnosis
• Hypertensive nephrosclerosis with secondary
Focal Segmental Glomerulosclerosis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS