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
 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
 Denies :
 Lightheadedness,
 Weight gain
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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:
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WBC 6.4
Hg/Hct 13.7/40.0
Platelets 236
MCV 83
RDW 14.6
N52 %
L 27 %
M16 %
E6%
B0%
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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
 UA: Protein 500 (neg),
 Albumin 2.4 (3.4-5.0)
 Bilirubin 0.5
 AST 31
 ALP 82
 ALT 19
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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
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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
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Surface Ag +
C3 111; C4 22
ESR 55 (0-15)
Rheumatoid Factor 162
(normal <20)
Total cholesterol 190
Triglycerides 44
HDL 54
LDL 127
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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 5/14/12
Diffuse 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
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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