lsu internal medicine case conference
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Silsbee Kemp MD Internal medicine HO III July 17, 2012. LSU Internal Medicine Case Conference. Chief Complaint. “I feel tired and my legs are swollen.”. History of Present Illness. - PowerPoint PPT PresentationTRANSCRIPT
LSU INTERNAL MEDICINE CASE CONFERENCE
Silsbee Kemp MDInternal medicine HO IIIJuly 17, 2012
Chief Complaint
“I feel tired and my legs are swollen.”
History of Present Illness
38 year-old man with no previous significant past medical history was in his usual state of health until two months ago when he began experiencing progressively worsening fatigue and decreased exercise tolerance Denies chest pain Denies SOB or DOE Denies PND
HPI
1 month ago, the patient was seen at an Urgent Care clinic complaining of a sore throat Denies respiratory symptoms Admits to subjective fevers Per patient, positive “rapid Strep test” Prescribed amoxicillin
Only completed 3 days
HPI
Soon after his Urgent Care clinic visit, the patient began experiencing progressively worsening lower extremity edema
1 week prior to admission, the patient presented to an outside facility for evaluation of this edema Diagnosed with renal failure Sent home with prescription for
furosemide
HPI
Since that time, the patient has not received any relief of his symptoms Difficulty standing on his feet for any
significant duration at work (+) nocturnal frequency,
Denies dysuria, urgency, polyuria, gross hematuria, decreased urine output
Denies excessive NSAID use Denies nausea, vomiting, diarrhea,
decreased oral intake
History continued…
PMHx: Denies PSHx: Denies Home Medications: Denies Allergies: NKDA FHx:
Mom with DM II Father unknown
History continued…
Social Hx: Lives with wife and children in Metairie,
LA 2 children ages 5 and 9 Denies tobacco, ETOH, IVDA or illicit
drugs Denies recent travel
Health Maintenance: Up to date on Tetanus only No PCP
Additional ROS:
Endorses : Generalized fatigue Weight gain
Denies : Lightheadedness,
Dizziness Headaches Blurry vision Abdominal pain Changes in bowel
habits Rashes
Vital signs
At initial presentation to UH: Temp 98.6° F BP 155/88 mmHg HR 61/min RR 12/min BMI 51; Ht 5’2 Weight 283lbs
Physical Exam
General: Alert & oriented, NAD HEENT: NC/AT, EOMI, PERRLA, Sclera
nonicteric, oropharynx clear with no exudates
Neck: FROM; No cervical LAD appreciated
CVS: RRR, No murmurs/S3/S4, JVP 12 Chest: CTA bilaterally, No crackles
/wheezes/rhonchi
Physical Exam
Abdomen: Nondistended, normoactive bowel sounds; soft, nontender, No organomegaly or masses appreciated
Ext: Bilateral pitting edema extending to upper thigh/lower back;2+ peripheral pulses
Skin: No rashes Neuro:
Cranial nerves II-XII intact Motor strength 5/5 Reflexes 2+ B/L upper and lower extremities
Labs:
WBC 6.4 Hg/Hct 13.7/40.0 Platelets 236 MCV 83 RDW 14.6 N52 % L 27 % M16 % E 6 % B 0 %
Na 142 K 4.8 Cl 108 CO2 27 BUN 53 (7-25) Cr 7.10 (0.7-1.4) Glucose 92 Ca 8.2 Phos 6.2 GFR 11 (>60)
Labs continued…
Total protein 6.1 Albumin 2.4 (3.4-
5.0) Bilirubin 0.5 AST 31 ALP 82 ALT 19
UA: Protein 500 (neg), 0-2 WBC/RBC, 2-20 squam , rare bacteria Hyaline casts
BNP 221 (<100) PT 10.1 INR 0.9 PTT 28.6
CXR
Renal Ultrasound Right kidney 12.8 x 6.2 6.3 Left Kidney 1 x 6.9 x 6.6 No hydronephrosis Increased echogenicity of cortex consistent with medical renal
disease
Hospital course cont….
Urine studies FENA 2.6% FEUrea 47.6% Spun urine: No casts or significant
sediment Urine Culture: No growth Urine Eos present Total protein 25943 mg/24hr (<100) Total protein/Creatinine ratio 12910
mg/g (<200)
Hospital course cont….Other significant lab values
HIV nonreactive RPR nonreactive Acute Hep panel: Hep
B Surface Ag + C3 111; C4 22 ESR 55 (0-15) Rheumatoid Factor
162 (normal <20) Total cholesterol 190 Triglycerides 44 HDL 54 LDL 127
ANA negative Anti-DS DNA negative LDH 289 (<201) CK 371 (<231) SPEP: Hypoalbuminemia
and increased fraction of alpha 2 consistent with Nephrotic syndrome
iPTH 296 (12-65); Calcium 8.2
25-OH Vit D 5.1 (32-100)
Follow-Up
Patient discharged 5/15/12 with diagnosis of nephrotic syndrome and Hepatitis B infection BUN 50; Cr 6.72; GFR 11 Discharge meds: furosemide, carvedilol,
amlodipine, atorvastatin, sevelamer No clear risk factors for Hepatitis B Hepatitis E Ag and Ab, HBV viral load Renal biopsy pathology pending at time
of discharge
After Discharge….Renal biopsy performed 5/14/12Diffuse foot process effacement with microvillus transformation and vacuolization. Unremarkable mesangial matrix and no deposits identified.Consistent with minimal change disease
Normal glomerulus
Light micrograph of an essentially normal glomerulus in minimal change disease.
Follow up
Patient seen in Nephrology clinic BUN 53; Cr 70.1; GFR 11 Hep B E Ag negative Hep B E Ag AB positive HBV viral load 3317 Oral prednisone 60mg daily started GI referral for hepatitis B management
Follow up
GI clinic 6/1/12 Chronic Hepatitis B carrier state Initiation of tenofovir renally dosed Monitoring with repeat labs at 2 and 6
months with repeat ultrasound at 6 months
Currently
Final Renal biopsy path report: Minimal Change
Weight 250 lbs BUN 32; CR 1.45 Total protein/Creat 3148 Tapering prednisone based on renal
function and proteinuria Requiring less fursoemide Tenofovir daily
THANK YOU