Age: 52.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Helicobacter test positive, Hepatitis B virus test, Hepatitis C virus test, Hydronephrosis, Impaired work ability
Clinical narrative: 52-year-old male presents with 4 day history of left-sided abdominal pain. He rates the pain is 8/10. No chest pain or radiation of the pain. Today was worse. Pain is more constant and is worse with active movement or taking a deep breath. No fever or chills. No change in pain with eating. It is tender when he presses on it. Bowel movements as per usual, he states he does have a history of constipation in the past. He has had previous left inguinal hernia repair otherwise no other abdominal surgeries. No new urinary symptoms. Pain has been interrupting his sleep. No previous colonoscopy, he denies history of diverticulitis. He has had hemorrhoids in the past and is wondering if this may be related. He has had some headache and some mild muscle aches. No cough or chest pain. Some nausea but no vomiting or diarrhea. Symptoms have caused a decreased appetite. No obvious injury or trauma but patient does have repetitive lifting and twisting at work per his report. He denies previous history kidney stone. No gross hematuria. The patient is a 52-year-old gentleman with no previous chronic medical problems, who was admitted from the emergency department for abdominal pain and renal failure. He said he first sought Urgent Care on 10/15 for left upper quadrant pain. No kidney function was checked on that day, but UA did show some microscopic hematuria, so he was sent for stone protocol CT, this was negative. He had telemedicine followup on 11/01 for the same left-sided pain and constipation. He was given MiraLAX. Today, he came into the ED because symptoms have been ongoing. Pain is intermittent, worse with inspiration and movement, and he feels very tired. Says he cannot eat. Says the food tastes terrible and he sometimes vomits. He has only been having some soup and water. He does keep most of it down and does not think he is dehydrated. He has been taking acetaminophen and ibuprofen for his pain, no more than 2 ibuprofen a day. He has had no fevers. He has noticed that his urine seems darker and occasionally red. He installs granite kitchen countertops. He said he has been able to go to work, but he says he is useless there because he is too weak. He really wants to know what should be done. In the ER, it was noted his creatinine was markedly elevated at 5. Urine sediment was active. CT scan showed significant swelling around his bilateral kidneys, but there was no fever. Patient was admitted. Nephrology saw him and noted that he had acute kidney injury and suspected autoimmune causes. They checked C3, C4, ANCA, anti-GBM, hepatitis B, hep C, and cryoprecipitate. He was also scheduled for renal biopsy. Renal biopsy, done 11/19/2021, showed diffuse crescentic necrotizing lesions consistent with a Pauci-immune glomerulonephritis, likely ANCA-associated glomerulonephritis. The patient was started on Solu-Medrol 1000 mg daily for 3 days and then transitioned to prednisone 60 mg a day. Patient's creatinine improved from 5 down to 3.4 on the 22nd. On the 23rd, his creatinine is still pending, but it is expected to be better. His hematuria has resolved. His weakness is improved. His appetite has come back down to baseline. At this time, suspect he has an autoimmune ANCA-associated glomerulonephritis and he is going to be treated with prednisone in the short term. He has a short interval followup plan with Rheumatology to start Rituxan. He will have follow up in 1 week with Nephrology. On 11/21/2021, the patient started complaining of a cough. He previously had no respiratory symptoms. Cough was a bloody tinged sputum, but had no other signs of respiratory distress and oxygenation was normal. Chest x-ray showed possible interstitial infiltrates, so a CT was done. This did show diffuse interstitial swelling that suggested he likely has lung involvement. This was discussed with Rheumatology. Recommended discontinuing him on the prednisone as the treatment would be the same. CT scan was also reviewed with Pulmonary. The patient developed some stomach upset with the prednisone and was started on Prilosec with control of his symptoms. He did note that he had a positive H pylori test on his previous part of his workup and he declined treatment at this time until his other symptoms are better controlled. At this time, kidney function is improved. He feels much better and doing well on oral prednisone. Plan is to discharge home. He will follow up with Rheumatology in 1-2 weeks for initiation of Rituxan. He will follow up with Nephrology in a week. He will avoid NSAIDs. He will take Prilosec daily. He was started on dapsone orally for PCP prophylaxis due to his planned immunosuppression. He did say that he is interested in finding a new primary physician. He works very near the Clinic and would like to establish primary care there. He was given a number to call.