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Physical Exam. Salient Features . History. A 50 y/o was referred for evaluation of azotemia .

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Presentation Transcript
history

Physical Exam

Salient Features

History
  • A 50 y/o was referred for evaluation of azotemia.
  • 10 yrs ago, he experienced sudden onset of pain on his right big toe. His serum uric acid was elevated. He was diagnosed to have gout and was prescribed medication but he was poorly compliant. The gouty attacks recurred lately hence, he decided to undergo thorough check-up. He denies dysuria, flank pain or hesitancy. He has nocturia.
  • BP is 120/70
  • Obese
  • numerous tophi in his metacarpo-phalangeal elbow joint
  • no edema
  • A 50 y/o obese male diagnosed 10 years ago to have gout with gouty attacks recurring lately and was referred for evaluation of azotemia
  • Patient experiences nocturia but there is no dysuria, flank pain or hesitancy, and edema
  • BP is 120/70
  • Numerous tophi in his metacarpo-phalangeal elbow joint
clinical impression
Clinical Impression
  • Gouty nephropathy
    • Patients with prolonged forms of hyperuricemia are predisposed to a more chronic tubulointerstitial disorder, often referred to as gouty nephropathy
    • Distinctive feature: presence of crystalline deposits of uric acid and monosodium urate salts in kidney parenchyma
  • Clinically, gouty nephropathy is an insidious cause of renal insufficiency.
  • Early in its course GFR may be near normal despite focal morphologic changes in medullary and cortical interstitium, proteinuria and diminished urinary concentrating ability
algorithm sequence of events

Gout

Renal Deposition of Urates

Parenchymal Urate

(microtophi)

Pelvic Calculi

Tubular Uric Acid

(obstruction)

Renal Insufficiency

Algorithm/Sequence of Events
differential diagnosis
Differential Diagnosis
  • Diabetic Nephropathy
    • Kimmelstiel-Wilson syndrome
    • a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli
    • characterized by nephrotic syndrome and diffuse glomerulosclerosis.
spectrum of disease diagram

Pretest probability

Upper testing threshold

Lower testing threshold

60%

70% %

20 %

Treat the patient without waiting for more information

Do additional diagnostic exams to confirm diagnosis (testing zone)

Do nothing. Rule out the disease

Spectrum of Disease Diagram