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BACKGROUND
A 56-year-old man with history of hepatitis C and
diabetes mellitus presents to the emergency department
with right flank pain and subjective fevers of 2-3 days'
duration. The patient describes his pain as mild in
intensity but constant. It is nonradiating, with a
pressure-like quality. The patient takes 20 units of
neutral protamine hagedorn (NPH) insulin injected
subcutaneously twice daily for his diabetes but states
that his self-reported daily blood glucometer readings
have been approximately 250-350 mg/dL for the past
month.
On physical examination, vital signs are a blood
pressure of 100/60 mm Hg, a heart rate of 96 beats per
minute, a respiratory rate of 16 breaths per minute, and
an oral temperature of 39.0°C. The cardiac and
respiratory portions of the examination are
unremarkable. The patient is noted to have tenderness in
the right costovertebral angle. His abdominal
examination is unremarkable for any tenderness to
palpation, rebound, or guarding.
Clinically significant laboratory results include a WBC
of 24.4 X 109/L, a blood urea nitrogen
concentration of 71 mg/dL, a creatinine level of 5.4 mg/dL,
and a serum glucose level 629 mg/dL. Urinalysis reveals
cloudy urine with copious WBCs, a glucose concentration
of 100 mg/dL, a protein concentration of 100 mg/dL, and
large leukocyte esterase.
Renal ultrasonography is performed and reveals an
abnormality of the right kidney (see Images 1-2). To
further illustrate this abnormality, an abdominal CT
scan was obtained (see Image 3). What is the diagnosis? |
Hint
This condition most commonly occurs in patients with
diabetes. |
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Authors:
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Pramod Gupta, MD, Staff
Radiologist, Dallas VA Medical Center, Texas
Nahid Eshaghi, MD, Acting Chief of Radiology, Dallas VA Medical Center,
Texas |
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eMedicine Editors:
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Erik Schraga, MD, UCLA - Olive
View Medical Center Residency, Department of Emergency Medicine, Olive
View - UCLA Medical Center
Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine,
Section of Emergency Medicine, Department of Surgery, Attending
Physician, Medical Director, Department of Emergency Services, Yale-New
Haven Hospital
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