Nephrology
A 28 yo woman is evaluated during a follow-up visit for elevated BP measurements during pregnancy. She is at 12 weeks' gestation of her first pregnancy. She feels well, and the pregnancy has been otherwise uncomplicated. She did not have routine medical care before her pregnancy. Family history is significant for HTN in her father and sister. Her only medication is a prenatal vitamin.
On exam, BP is 155/95 mm Hg; other vital signs are normal. Funduscopic, neurologic, and cardiac examinations are normal.
Labs are normal.
What is the most likely cause of this patient's elevated blood pressure?
What is chronic hypertension?
A 29 yo woman undergoes a new-patient evaluation. She is a full-time college student, works part time as a waitress, and runs 3 miles twice weekly, but she is mildly fatigued in the evening. PMH is significant for hereditary spherocytosis diagnosed at age 10 years. Her only medication is folic acid.
On exam, temperature is 36.3 °C (97.4 °F), blood pressure is 133/62 mm Hg, pulse rate is 68/min, and respiration rate is 18/min. She has scleral icterus and no lymphadenopathy. Cardiopulmonary examination is normal. On abdominal examination, the spleen is palpable just below the left costal margin.
Labs:
Hemoglobin 11.2 (compared with a value of 11.5 3 years ago)
Leukocyte count 5900
MCV 103 fL
Platelet count 172,000
Reticulocyte count 3.4% of erythrocytes
An abdominal ultrasound shows mild splenomegaly and no gallstones.
What is the most appropriate treatment?
What is supportive care?
A 69-year-old woman is evaluated in follow-up after a recent hospitalization for gastrointestinal bleeding. One week ago, she was admitted to the hospital with a diagnosis of lower gastrointestinal bleeding secondary to colonic angiodysplasia that resolved spontaneously. Medical history is otherwise significant for atrial fibrillation, hypertension, type 2 diabetes mellitus, and two episodes of gastrointestinal bleeding in the past 18 months during separate trials of warfarin and dabigatran. During these episodes of gastrointestinal bleeding she was never hemodynamically unstable. Before this hospitalization, she was taking apixaban. Upon admission, apixaban was held. Other medications are metformin, metoprolol, candesartan, and simvastatin.
On physical examination, vital signs are normal. Cardiac examination reveals an irregular rhythm. The remainder of the physical examination is unremarkable.
What is the most appropriate management of the patient's atrial fibrillation?
What is left atrial appendage occlusion?
A 38 yo woman is evaluated for elevated results of liver chemistry tests detected in an evaluation for new-onset fatigue, joint pains, and jaundice. She recently started a job in a hospital and received a hepatitis B virus vaccination. She has a history of hypothyroidism, and her only medication is levothyroxine. She has never used illicit drugs and does not drink alcohol. Her mother has rheumatoid arthritis.
On exam, the patient is afebrile. BP is 130/75 mm Hg, HR is 80/min, and RR is 16/min. BMI is 26. Scleral icterus is noted. The examination is otherwise normal.
Labs:
Leukocyte count 3400 with a normal differential
AST 890
ALT 765
Alkaline phosphatase 120
Total bilirubin 6.0
Direct bilirubin 3.6
Antinuclear antibody Titer 1:40
Anti–smooth muscle antibody Titer 1:640
Antimitochondrial antibody Negative
Viral serologies Negative
What is the most likely diagnosis?
What is autoimmune hepatitis?
A 73 yo woman is hospitalized for an elevated serum creatinine level that has been unresponsive to intravenous fluids. She was evaluated in the ED 2 days ago for weakness, myalgia, arthralgia, and cough and admitted to the hospital. She has no other medical history and takes no medications.
On exam, the patient is afebrile. BP is 155/95 mm Hg, pulse rate is 70/min, and oxygen saturation is 98% breathing 2 L of oxygen per minute by nasal cannula. Cardiac examination is normal, without evidence of jugular venous distention. Dullness to percussion and diminished breath sounds are present at the posterior lung bases bilaterally. There is pitting lower extremity edema.
Labs:
Hemoglobin 9.9
Creatinine - Baseline 6 months ago: 0.7; ED: 4.1; Hospital day 1: 4.3
Antinuclear antibodies Negative
Antimyeloperoxidase antibodies Positive
Antiproteinase 3 antibodies Negative
Urinalysis :3+ blood; 2+ protein
Chest radiograph shows diffuse infiltrates at the lung bases bilaterally.
Kidney biopsy shows necrotizing and crescentic glomerulonephritis with linear staining for IgG on immunofluorescence.
What is the most appropriate diagnostic test to perform next?
What is anti–glomerular basement membrane (GBM) antibodies?
A 29 yo man is evaluated in the ED for dyspnea and diffuse severe pain in the arms, legs, back, and chest x 2 days. He has sickle cell anemia and experiences painful episodes one to two times per year. He also has a history of acute chest syndrome and has known erythrocyte alloantibodies. In addition to increased fluid intake at home, he has been taking oral morphine sulfate, 30 mg twice daily, with no relief. He also takes hydroxyurea and folic acid.
On exam, temperature is 36.8 °C, blood pressure is 153/65 mm Hg, HR is 108/min, and RR is 20/min. Oxygen saturation is 95% on room air. The patient is hunched over in pain, and he is diffusely tender to touch. Cardiopulmonary, abdominal, and neurologic examinations are normal.
Labs:
Hemoglobin 7.2
Leukocyte count 11,900 with a normal differential
Platelet count 199,000
Reticulocyte count 5.4% of erythrocytes
LDH420 U/L
The patient has alloantibodies to antigens C, E, and K on blood typing and screening.
In addition to IV hydration and incentive spirometry, what is the most appropriate initial treatment?
What is IV opioids?
A 53-year-old woman is evaluated for recent onset of palpitations. Until the onset of palpitations, the patient was asymptomatic. She has hypertension treated with chlorthalidone and type 2 diabetes mellitus treated with metformin.
On physical examination, pulse rate is 87/min and irregular; other vital signs are normal. Cardiovascular examination reveals an irregular rhythm with variable intensity of S1; an opening snap and a grade 2/6 diastolic rumbling murmur are heard at the cardiac apex.
An electrocardiogram shows atrial fibrillation but is otherwise unremarkable. Transthoracic echocardiographic findings are consistent with rheumatic mitral valve stenosis of moderate severity.
What is the most appropriate management to prevent thromboembolism in this patient?
What is start warfarin?
A 35 yo woman comes to the office to discuss recent laboratory test results. She is asymptomatic. PMH includes T2DM, HTN, HPLD, obesity, and the metabolic syndrome. The patient has a sedentary lifestyle. She does not smoke cigarettes and drinks one alcoholic beverage weekly. Her current medications include metformin and lisinopril. Atorvastatin was initiated 3 weeks ago.
Exam findings, including vital signs, are normal. BMI is 32.
On labs, AST is 76 U/L and ALT is 83 U/L. These results are unchanged from 3 months ago. Results of serologies for antinuclear antibody and viral hepatitis infection are negative; transferrin saturation is 20%.
In addition to aggressive lifestyle intervention, what should be done next?
What is RUQ US?
A 79 yo woman is evaluated for hyperkalemia. She was admitted to the surgical ICU after having an urgent partial colectomy for a ruptured diverticulum with peritonitis. She was treated with intravenous fluids, antibiotics, and vasopressor therapy. Today, postoperative day 1, she is oliguric with urine output <5 mL/h for the past 4 hours. She is now weaned off the vasopressor therapy. History is significant for hypertension and stage G4 chronic kidney disease. Outpatient medications are amlodipine, irbesartan, and furosemide. Current medications are morphine, propofol, cefotaxime, and metronidazole.
On exam, the patient is intubated and mechanically ventilated. A urinary catheter is in place. Temperature is 38.9 °C, BP is 108/70 mm Hg, and pulse rate is 101/min. There is generalized anasarca. The abdomen is distended and quiet.
Labs:
Creatinine 3.6 ; baseline, 2.0
Electrolytes: Sodium 142
Potassium 7.1
Chloride 102
Total bicarbonate 17
Arterial pH 7.25
Urine sediment: Brown granular casts
ECG shows peaked T waves with a QRS of 140 ms.
In addition to intravenous calcium, insulin, and dextrose, what is the most appropriate treatment?
What is hemodialysis?
A 21 yo woman is seen for follow-up evaluation after a hospitalization 1 week ago for an acute ischemic stroke in the R middle cerebral artery distribution. In the hospital, she was treated with blood transfusion and aspirin. She is homozygous for hemoglobin S (Hb SS) and experiences frequent pain crises; she has had two episodes of acute chest syndrome within the past 3 years. Medications are folic acid, hydroxyurea, and low-dose aspirin.
On exam, temperature is 36.7 °C (98.0 °F), blood pressure is 120/70 mm Hg, HR is 90/min, and RR is normal. She has L-sided weakness of the upper and lower extremities. No hepatosplenomegaly is noted.
Labs at hospital discharge showed a posttransfusion hemoglobin level of 10 and LDL cholesterol level of 92.
What is the most appropriate management to prevent subsequent stroke in this patient?
What is monthly pRBC transfusions?
A 52 yo woman is evaluated for a 6-week history of chest pressure. The symptom occurs when she walks up an incline on her daily 2-mile walk and is relieved with rest. She also had chest pressure during a stressful meeting at work last week. She reports no associated symptoms. PMH is significant for hypertension and hyperlipidemia. Medications are hydrochlorothiazide, lisinopril, and atorvastatin.
On exam, vital signs and the remainder of the exam are normal.
An ECG is normal.
What is the most appropriate diagnostic test to perform next?
What is exercise ECG stress test?
A 35 yo man is evaluated for a 1-year history of near-daily postprandial diarrhea, episodic abdominal cramping relieved with a bowel movement, and abdominal bloating. He is otherwise healthy, and his only medication is loperamide. This treatment has not been consistently effective in reducing diarrhea symptoms and has had no effect on the cramping and bloating, despite increased frequency of dosing.
Vital signs are normal. Diffuse tenderness to abdominal palpation is noted. Other physical examination findings are normal.
Stool testing for infection and celiac antibody testing are negative.
Colonoscopy findings are unremarkable.
What is the most appropriate treatment?
What is a low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) diet?
A 42 yo woman is evaluated in the ED for right flank pain of 3 hours' duration. History is significant for migraines. There is no family history of kidney stones. Medications are as-needed sumatriptan and daily topiramate.
On exam, R CVA tenderness is present.
Labs:
Creatinine 0.8
Sodium: 138
Potassium 3.5
Chloride 104
Bicarbonate 21
Urinalysis : Specific gravity 1.005; pH 6.5; 1+ blood; negative leukocyte esterase; negative nitrites; 20-30 erythrocytes/hpf; 1-3 leukocytes/hpf; amorphous crystals
Noncontrast helical CT scan shows a 5-mm stone in the right proximal ureter.
What is the most likely composition of this patient's kidney stone?
What is calcium phosphate?
A 53 yo woman undergoes follow-up evaluation for anemia found incidentally on routine laboratory testing. She reports no specific symptoms. Medical history is remarkable for stable autoimmune hepatitis. Her only medication is azathioprine.
On exam, vital signs are normal. Hepatomegaly is palpated on abdominal examination.
Labs:
Hemoglobin 11.5
Leukocyte count 7000
Platelet count 300,000
Albumin 4
Ferritin 300
Total iron-binding capacity 189
Protein , total 10 g/dL
Serum protein electrophoresis and immunofixation show a polyclonal pattern with elevated IgG levels.
What is the most appropriate next step in evaluating the elevated protein?
What is no further testing?
A 33 yo woman was hospitalized 8 days ago for fever and severe dyspnea. Her current symptoms began 1 month ago with chills, malaise, and low-grade fever. She was diagnosed 5 years ago with a bicuspid aortic valve with regurgitation but had been healthy otherwise. On admission, an echo demonstrated a 12-mm vegetation involving the aortic valve with severe regurgitation and preserved left ventricular function. Blood cultures grew Staphylococcus aureus that was sensitive to oxacillin. After 8 days of IV antimicrobial therapy, she has continued to be febrile, and her dyspnea has progressed such that she has symptoms at rest.
On exam, temperature is 38.1 °C (100.6 °F), blood pressure is 110/60 mm Hg, pulse rate is 96/min, and respiration rate is 23/min. Lung examination demonstrates bilateral crackles. The estimated central venous pressure is 10 cm H2O. There is a grade 3/6 diastolic decrescendo murmur along the left sternal border. An S3 is present.
Repeat blood cultures performed yesterday continue to grow S. aureus sensitive to oxacillin. An echocardiogram obtained today shows findings similar to those on the initial study done at admission. A transesophageal echocardiogram confirms the valve findings without evidence of additional complications.
What is the most appropriate next step in management?
What is cardiac valve surgery?
A 21-year-old woman is evaluated in follow-up for a recent diagnosis of biopsy-confirmed ulcerative colitis. She has a 6-week history of three daily bowel movements with passage of small amounts of blood and mucus without fever, nausea, or weight loss. She is otherwise healthy and takes no medication.
On physical examination, vital signs are normal. The abdomen is scaphoid, with tenderness to palpation in the suprapubic area.
Laboratory studies show a normal complete blood count and C-reactive protein level. Results of stool testing for enteropathogens, including Clostridium difficile, are negative.
Results of colonoscopy performed 7 days ago showed continuous, symmetric rectal and sigmoid inflammation. The remainder of the colonic mucosa and distal ileum was normal.
What is the most appropriate treatment?
What is oral and rectal mesalamine?
A 77 yo man is evaluated for a 2-month history of worsening fatigue, increasing frequency of urination, nocturia, and anorexia. PMH of hypertension, hypertriglyceridemia, GERD, and depression. He has been taking low-dose aspirin and valsartan for more than 10 years, omeprazole and St. John's wort for 8 months, and fenofibrate for 2 months.
On exam, BP is 150/79 and HR is 82/min. The remainder of the exam is unremarkable.
Labs:
Creatinine 2.8; 9 months ago: 1.2
Urinalysis: Specific gravity 1.008; trace blood; 2+ protein; 3-5 erythrocytes/hpf; 5-7 leukocytes/hpf
Kidney ultrasound shows 9-cm kidneys without hydronephrosis or calculi bilaterally.
What is the most likely cause of the patient's kidney findings?
What is omeprazole?
A 34 yo woman is evaluated 2 weeks after a diagnosis of malignant melanoma. An enlarging mole on her left lower leg was resected with wide excision, and pathologic evaluation showed malignant melanoma, invading 0.4 mm by Breslow microstaging. The original lesion was 1.2 cm in diameter and was not associated with bleeding or ulceration.
On exam, vital signs are normal. There is a healed excision site on the left lower leg without evidence of residual disease. There is no inguinal lymphadenopathy. The remainder of the exam is normal.
What is the most appropriate management?
What is follow up in 12 months?
A 40-year-old woman is evaluated for a 7-month history of progressive dyspnea with mild exertion that interferes with her activities of daily living. She has not had symptoms at rest and has no other cardiovascular symptoms. She has no other medical problems and does not take any medication.
On physical examination, vital signs are normal. The cardiac examination reveals a diastolic opening snap followed by a rumbling diastolic murmur heard best at the cardiac apex. The remainder of the physical examination is normal.
An echocardiogram shows findings consistent with mild to moderate rheumatic mitral stenosis (mitral valve area, 1.8 cm2) and minimal mitral regurgitation. Moderate pulmonary hypertension is present. The mitral valve is pliable.
What is the most appropriate next step in management?
What is exercise ECHO?
A 53 yo woman is evaluated for an 8-month history of fatigue and pruritus without rash. She has no other symptoms. Her only other medical problem is a 2-year history of hypercholesterolemia for which she takes simvastatin.
On exam, vital signs are normal. BMI is 24. Other than excoriations on her arms, legs, and upper back, the physical examination is normal.
Labs:
ALT 75
AST 54
Alkaline phosphatase 328
Total bilirubin 1.2
Direct bilirubin 0.6
Antimitochondrial antibody Negative
Ultrasound of the right upper quadrant is normal.
What diagnostic tests should be done next?
What is measurement of sp100 and gp210 antibodies?