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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