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Clinical Case 1
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Objectives:

  • Evaluate and follow a healthy-appearing patient with proteinuria
  • Define and diagnose orthostatic proteinuria and understand its significance
  • Manage a patient with progressive proteinuria
  • Recognize nephrotic syndrome
  • Identify causes of nephrotic syndrome
  • Evaluate and treat a patient with Goodpasture's syndrome



1

A 27-year-old female presents to your office complaining of dyspnea and cough productive of blood. She has had fever, arthralgias, and weight loss as well. She is a smoker. Chest radiograph shows patchy infiltrates. You consider SARS but find that she hasn't traveled. You consider Goodpasture's syndrome and take an occupational history. It is of note that she is an office worker without any exposure to hydrocarbons.

Your interpretation of this information is:

A)Smoking is a common precipitant of Goodpasture's syndrome.
B)Goodpasture's syndrome is unlikely because she is not exposed to hydrocarbons.
C)This presentation is more consistent with SARS and health authorities should be contacted despite the lack of travel.
D)"Nil" disease with pulmonary involvement is the more likely explanation for this patient's symptoms.
E)None of the above is true.
2

Since this is the nephrology chapter, you of course want to order a urinalysis. For some unknown reason, your laboratory staff has forgotten to stock urine dipsticks and all of the microscopes are broken (seems like a common occurrence in our hospital!!). However, you are able to get a CBC, which shows a normal white count with a normal differential.

Given her history and laboratory findings, diagnostic considerations in this patient include all of the following EXCEPT:

A)Wegner's granulomatosis.
B)Neoplasm.
C)Lupus erythematosus.
D)Churg-Strauss disease.
E)All of the above.
3

The next day the laboratory staff finds the dipsticks and the patient is noted to have an active sediment (protein, white cells, red cell casts, etc.) along with an elevated creatinine of 2.5 mg/dl. You decide to check an anti-glomerular basement membrane titer (anti-GBM). This returns positive and you make the presumptive diagnosis of Goodpasture's syndrome.

The next step in the treatment of this patient is to:

A)Initiate steroids.
B)Initiate dialysis to preserve renal function.
C)Initiate plasmapheresis to remove anti-GBM from the serum.
D)Initiate plasmapheresis, steroids, and cyclophosphamide.
E)Begin watchful waiting since most cases are self-limited.







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