Transcript Journal Club - NYU Langone Medical Center
NYU Medical Grand Rounds Clinical Vignette
Neelja Kumar, MD PGY 3 October 20, 2010
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
Chief Complaint
• 54 year old African American man presenting with left sided testicular pain for one week
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
Other Studies
• Electrocardiogram: normal sinus rhythm with left ventricular hypertrophy • Testicular ultrasound: mildly complex bilateral hydroceles
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
Working or Differential Diagnosis
• Orchitis • Stage 3 Chronic kidney disease secondary to hypertensive nephrosclerosis
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
Hospital Course
• Hospital Day 5: – Testicular pain resolved • Hospital Day 7: - Given renal failure and findings on renal ultrasound, a renal biopsy was performed
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
Renal Biopsy
Duplication of elastic lamina in interlobular artery Hematoxylin and Eosin Stain: sclerosis with hyalinosis
Periodic acid-Schiff stain: segmental sclerosis and adhesion to Bowman’s capsule
Renal Biopsy
Final Diagnosis
• Hypertensive nephrosclerosis with secondary Focal Segmental Glomerulosclerosis.
U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS