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NYU Medicine Grand Rounds Clinical Vignette

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Title: Journal Club Author: Louis Miller Last modified by: mosesn01 Created Date: 5/22/2007 12:58:19 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: NYU Medicine Grand Rounds Clinical Vignette


1
NYU Medicine Grand Rounds Clinical Vignette
  • Han Na Kim
  • PGY-2
  • January 26, 2011

2
Chief Complaint
The patient is a 24-year-old man with a past
medical history of cystinuria, presenting to
renal stone clinic for routine follow up.
3
History of Present Illness
  • The patients medical history began at age 11
    when he was diagnosed with cystinuria after an
    incidental finding of a large staghorn calculus.
  • The stone was removed percutaneously but the
    kidney had minimal recovery of glomerular
    filtration.

4
History of Present Illness
  • Since that time, he has had multiple episodes of
    acute on chronic renal failure secondary to
    nephrolithiasis in the contralateral kidney.
  • Because the patients cystinuria was refractory
    to medical treatment, a left ileal ureter was
    created with a segment of bowel replacing the
    proximal 2/3 of the left ureter six years prior
    to admission.

5
History of Present Illness
  • The patient has since been doing well, until six
    months prior to presentation, when he stopped
    taking his medications, including tiopronin (a
    thiol) and potassium citrate, used for urinary
    alkalinization.
  • He now presents to renal stone clinic for routine
    follow up.

6
Additional History
  • Past Medical History
  • Cystinuria diagnosed 1997
  • Hypertension diagnosed 2000
  • Past Surgical History
  • Multiple percutaneous nephrolithotomies
  • Left ureteral stent placement 2004
  • Creation of ileal ureter 2005
  • Social History
  • Denies tobacco or drug use and drinks alcohol
    occasionally. Works at a pharmaceutical company.

7
Additional History
  • Family History
  • Father
  • Renal Cell Carcinoma
  • Obstructive Pulmonary Disease
  • Sister Cystinuria
  • Allergies No known drug allergies
  • Medications (stopped taking six months prior to
    presentation)
  • Lisinopril 10 mg daily
  • Potassium Citrate 20 meq twice daily
  • Tiopronin 2400 mg daily

8
Physical Examination
  • General well appearing obese young male in no
    apparent distress
  • Vital Signs T 98.6 F BP 126/88 HR 76 RR 14
    and O2 sat 98 on room air
  • Remainder of the physical exam was normal

9
Laboratory Findings
  • CBC within normal limits
  • Basic Metabolic panel
  • BUN 30
  • Creatinine 1.4
  • Remainder of the basic metabolic panel was
    within normal limits
  • Hepatic panel within normal limits

10
Laboratory Findings
  • Urinalysis
  • pH 7.3 (4.5-8)
  • Specific Gravity 1.005 (1.005-1.030)
  • Negative protein
  • Negative nitrate
  • Small blood
  • Small leukocyte esterase
  • Microscopic analysis
  • Red blood cell count 3-4
  • White blood cell count 5-6

11
Working Diagnosis
  • Concern for cystine stone reformation in the
    setting of medication non-adherence in a patient
    with cystinuria.

12
CAT Scan Abdomen and Pelvis
13
CAT Scan Abdomen and Pelvis
14
Ileal Ureter
15
Renal Ultrasound
  • Atrophic right kidney with multiple echogenic
    stones throughout the parenchyma mostly in lower
    pole. No solid mass lesions
  • Left kidney with component of compensatory
    hypertrophy. Three stones noted with largest one
    in the lower pole measuring 7.2 mm

16
Working Diagnosis
  • Cystine stone formation secondary to nonadherence
    with medications in this patient with known
    diagnosis of cystinuria.

17
Course
  • Patient was instructed to restart potassium
    citrate at a higher dose of 3 tablets twice daily
    and to maintain a high fluid intake and reduce
    dietary sodium and animal protein intake.

18
Final Diagnosis
  • Cystinuria with cystine stone formation secondary
    to medication non-adherence.
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