A 55-year-old man comes to the office for a medical evaluation for life insurance.  The patient feels well and has no chronic health issues.  He takes no prescription medications but recently began taking over-the-counter supplements, which have improved his energy level.  The patient has smoked a pack of cigarettes a day for 30 years but is trying to cut down.  He drinks alcohol occasionally and does not use illicit drugs.  Family history is notable for non-Hodgkin lymphoma in his brother.  Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 80/min, and oxygen saturation is 99% on ambient air.  The patient’s complexion is ruddy.  There are no skin rashes or mucosal lesions.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  Laboratory results are as follows:

Item 1 of 2

In addition to recommendation for smoking cessation, which of the following is the best next step in management of this patient?

Item 2 of 2

Imaging studies reveal a complex cystic mass with enhancing soft-tissue components and thick, irregular septa in the right kidney.  Which of the following is the best intervention for this patient’s current renal condition?

A 76-year-old man comes to the office for follow-up of aortic valve infective endocarditis, and laboratory testing shows new-onset kidney dysfunction.  The patient initially sought care 3 weeks ago with intermittent fever, malaise, and fatigue.  Blood cultures grew viridans streptococci, and echocardiography revealed an aortic valve vegetation.  He has been receiving intravenous ceftriaxone infusions at home, and the symptoms are resolving.  The patient has had adequate oral intake and has not had nausea, anorexia, hematuria, or decreased urine output.  Medical history also includes hypertension and osteoarthritis.  Vital signs are within normal limits.  Physical examination shows a new morbilliform rash on the chest but is otherwise unremarkable.  Laboratory results are as follows:

Ceftriaxone is stopped, and an antibiotic of a different class is started.  Which of the following additional interventions is the best next step in the management of this patient?

An 80-year-old man with advanced chronic kidney disease is evaluated for worsening fatigue.  Medical history is significant for heart failure with reduced ejection fraction of 30%, coronary artery bypass graft, type 2 diabetes mellitus, and degenerative joint disease.  Medications include aspirin, carvedilol, spironolactone, torsemide, empagliflozin, and atorvastatin.  The patient lives alone and uses a cane and wheelchair; he has had increasing difficulty with activities of daily living.  Blood pressure is 106/64 mm Hg, pulse is 80/min, and respirations are 16/min.  Oxygen saturation is 96% on room air.  BMI is 19 kg/m².  The patient appears thin and frail.  Examination shows bibasilar crackles and 2+ lower extremity edema.  Laboratory results are as follows:

Which of the following is a major determinant in choosing the most appropriate therapy for this patient’s kidney disease?

A 60-year-old woman comes to the emergency department due to right wrist pain and swelling after falling on an icy sidewalk.  She sustained no head injury and did not lose consciousness.  Two years ago, the patient was told that she has high blood pressure and mild kidney damage, but she did not follow up.  She currently takes no medications.  The patient smokes a half-pack of cigarettes daily.  Blood pressure is 160/94 mm Hg and pulse is 90/min.  The right wrist is swollen and tender with no gross deformity.  No abnormalities are noted on the remainder of the physical examination.  Laboratory results are as follows:

Serum vitamin D level is within normal limits.  Radiography of the right hand and wrist reveals no fracture.  What is the most appropriate next step in management of this patient?

A 32-year-old woman with systemic lupus erythematosus comes to the office for a follow-up visit.  The patient was diagnosed with lupus 3 years ago during evaluation of a skin rash and joint pain, and her symptoms have been well controlled with hydroxychloroquine.  She takes no other medications, has no other medical conditions, and does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 150/90 mm Hg and was normal during previous office visits.  Temperature is 37.2 C (99 F), pulse is 78/min, and respirations are 14/min.  There is a faint malar rash but no mucosal ulcers, joint tenderness, or swelling.  The lungs are clear on auscultation and heart sounds are normal with no murmur, rub, or gallop.  The abdomen is soft and nontender with no hepatosplenomegaly.  There is mild pitting edema of the bilateral lower extremities.  Neurologic examination shows no abnormalities.  Laboratory results are as follows:

The patient’s serum chemistry and urinalysis were within normal limits 2 months ago.  Renal ultrasonography shows normal-sized kidneys with no hydronephrosis.

Item 1 of 2

Which of the following is the best next step in management of this patient?

Item 2 of 2

Renal biopsy reveals diffuse lupus nephritis (Class IV) and appropriate therapy is initiated.  Which of the following is most appropriate for monitoring the renal disease activity in this patient?

A 48-year-old man is brought to the emergency department by his wife due to confusion for the last 2 days.  Medical history is significant for cirrhosis due to chronic hepatitis C infection.  Home medications include spironolactone, lactulose, and furosemide.  Examination shows a drowsy but agitated patient.  Temperature is 37 C (98.6 F), blood pressure is 94/56 mm Hg, and pulse is 102/min with a regular rhythm.  The abdomen is distended, soft, and nontender to palpation.  Shifting dullness is present.  There is no peripheral edema.  Laboratory results are as follows:

Diagnostic paracentesis yields clear fluid with a neutrophil count of 12/mm³ and an albumin level of 1.0 mg/dL.  Renal ultrasonography shows no hydronephrosis.  Which of the following is the best next step in management of this patient’s renal dysfunction?

An 80-year-old woman is evaluated during a new patient visit.  She has had no concerns since she saw her previous primary care physician a year ago.  Medical history is significant for hypertension, osteoporosis, and hypothyroidism.  Medications include lisinopril, alendronate, calcium, vitamin D, and levothyroxine.  Blood pressure is 122/75 mm Hg and pulse is 82/min.  Physical examination is normal.  Laboratory results are as follows:

Urinalysis reveals trace protein without blood or casts.  Urine albumin/creatine ratio is 20 mg/g.  Which of the following is the best next step in management of this patient’s decreased estimated glomerular filtration rate?

A 17-year-old boy is evaluated for abnormal urinalysis findings.  He came to the clinic 2 weeks ago with low back pain, and a urinalysis at that time showed 2+ protein.  He currently feels fine and has no urinary complaints.  The patient has not exercised vigorously or taken any medications.  He has no other medical problems and received all appropriate childhood vaccinations.  He does not use tobacco or illicit drugs.  The patient is not sexually active.  His father had early coronary disease and a stroke.  His blood pressure is 112/70 mm Hg and pulse is 77/min.  BMI is 24 kg/m².  Physical examination shows no abnormalities.  Laboratory results from this visit are as follows:

Urine sediment microscopy is unremarkable for casts.  A 24-hour urine collection shows 600 mg of protein (normal <150 mg).

Item 1 of 2

Which of the following is the best next step in management of this patient?

Item 2 of 2

Ultrasound of the kidneys shows no abnormalities.  Split urine collection shows 40 mg of protein overnight (8 hours) and 500 mg of protein during the day (16 hours).  Which of the following is the best next step in management of this patient?

A 70-year-old white male with a history of hypertension, hypercholesterolemia, and degenerative joint disease presents to the office because of worsening fatigue, nausea, malaise, and bilateral pedal edema.  He also complains of a decreased appetite for the past six weeks.  Four weeks ago, he had an upper respiratory tract infection that resolved with over-the-counter medications.  He describes his degenerative joint disease as moderately severe, and for which, he has been taking ibuprofen for the past year.  His other daily medications for the past six years are metoprolol, hydrochlorothiazide, hydralazine, and simvastatin.  He has no known drug allergies.  He has a 50-pack-year history of smoking, and occasionally drinks alcohol.  His family history is significant for strokes.  His labs on this office visit show the following:

His urine analysis shows: 4+ protein, 0-1 RBC/HPF, 20-25 WBC/HPF, and a few granular casts.  His 24-hour urine protein is 7 g.  Ultrasound of the kidneys is unremarkable.  His antinuclear antibody titers are 1:40.  During his previous visit one year ago, the creatinine was 1.2.  Which of the following is the most likely cause of his presentation?

A 42-year-old man comes to the emergency department due to 4 days of nausea, skin rash, progressive weakness, and decreased urine output.  For the past few months he has also had fatigue, tingling in his hands and feet, and occasional joint pains.  The patient has had no fever, chest pain, dysuria, hematuria, or diarrhea.  He has no chronic medical problems and takes no medication.  The patient does not use tobacco or alcohol but used injection drugs during his early 20s.  Temperature is 37.6 C (99.8 F), blood pressure is 150/90 mm Hg, pulse is 92/min, and respirations are 16/min.  BMI is 24.8 kg/m².  Mucous membranes are dry with no lesions.  Cardiopulmonary auscultation is normal.  The liver edge is palpable 2 cm below the right costal margin.  Bilateral ankle reflexes are absent.  He has mild, bilateral, lower-extremity pitting edema and a palpable, nonblanchable, purpuric rash on both legs.  There is no joint swelling or erythema.  Laboratory results are as follows:

Item 1 of 2

Which of the following is most helpful in establishing the cause of this patient’s renal dysfunction?

Item 2 of 2

The diagnosis is established and the patient’s renal function stabilizes with initial therapy.  Which of the following is most appropriate for the long-term management of this patient?

A 43-year-old woman is brought to the emergency department due to confusion and lethargy over the past day.  The patient’s husband reports that she also has been excessively thirsty for several days, which she attributed to the summer heat.  She also has been urinating more frequently, including at least 2 or 3 times every night.  The patient has had no associated fever, chills, abdominal pain, or dysuria.  Medical history is significant for bipolar disorder that is well controlled with medication.  She does not use tobacco, alcohol, or recreational drugs.  Temperature is 37.2 C (99 F), blood pressure is 118/70 mm Hg, pulse is 92/min, and respirations are 16/min.  The patient appears somnolent and mildly disoriented but follows all instructions and has no focal neurologic deficits.  The abdomen is soft and nontender.  Laboratory results are as follows:

Which of the following is the most likely underlying cause of this patient’s current condition?

A 42-year-old woman comes to the office for evaluation of elevated blood pressure.  She says, “I checked my blood pressure on a machine at the pharmacy, and it was 160/90 mm Hg.  The pharmacist said I should see a doctor.”  The patient has no history of hypertension and has had no chest pain, headache, or focal weakness or numbness.  She notes occasional episodes of pain in her flanks, which she ascribes to muscle tension.  The patient has had several urinary tract infections over the course of her life but has no chronic medical problems and takes no medication regularly.  She does not use tobacco, alcohol, or illicit drugs.  The patient is married and has a son.  Her mother has hypertension, her father died at an early age in a motor vehicle collision, and her uncle has renal failure and receives dialysis.  Blood pressure is 156/94 mm Hg on the right arm and 152/96 mm Hg on the left arm.  Pulse is 80/min and respirations are 16/min.  Jugular venous pressure is within normal limits.  Breath sounds are normal bilaterally with no crackles.  Point of maximal impulse is displaced to the left and down.  Heart sounds are normal with no murmur or gallops.  The abdomen is soft with bilateral flank fullness.  Bowel sounds are active.  Laboratory results are as follows.

Urinalysis shows dysmorphic erythrocytes and mild proteinuria.  ECG shows left ventricular hypertrophy with nonspecific ST-T wave changes.

Item 1 of 3

Which of the following is the best next step in management of this patient?

Item 2 of 3

Imaging reveals enlarged kidneys with multiple bilateral cysts.  Which of the following is the best management for this patient?

Item 3 of 3

After learning about the disease, the patient becomes worried that her 19-year-old son may also have the same condition.  Which of the following is the most appropriate response to the patient?

n 86-year-old man is brought to the emergency department from a nursing home due to generalized weakness.  The nursing home staff noticed that the patient has also been less attentive for the past several days.  Medical history is significant for hypertension, benign prostatic hyperplasia, and chronic kidney disease.  Medications include lisinopril, amlodipine, and tamsulosin.  Temperature is 37.1 C (98.8 F), blood pressure is 172/105 mm Hg, pulse is 88/min, and respirations are 16/min.  BMI is 41 kg/m².  On physical examination, the patient is alert and oriented to name only with impaired attention.  Mucous membranes are moist.  Cranial nerves, muscle strength, and sensation are normal.  Cardiopulmonary examination shows a regular rhythm and clear lungs.  The abdomen is obese.  The prostate is diffusely enlarged and is without nodules or tenderness.  Bilateral 1+ lower extremity pitting edema is present.  Laboratory findings are as follows:

Urinalysis shows a specific gravity of 1.009 with 1+ protein.  ECG is normal.  Lisinopril is held.  Which of the following is the best next step in management of this patient?

A 60-year-old man comes to the office for an initial evaluation of fatigue and dyspnea on exertion.  Medical history is significant for hypertension and chronic kidney disease with a baseline serum creatinine of 2.5-3.0 mg/dL.  Temperature is 36.1 C (97 F), blood pressure is 145/92 mm Hg, and pulse is 80/min.  BMI is 28 kg/m².  Physical examination shows displacement of the apical impulse to the left and downward and 1+ bilateral lower extremity edema.  The remainder of the physical examination shows no abnormalities.  ECG reveals left ventricular hypertrophy with repolarization abnormalities.  Laboratory results are as follows:

Treatment with an erythropoietin-stimulating agent would most likely have a beneficial impact in terms of which of the following in this patient?

A 40-year-old man is evaluated for perioral paresthesias and cramping of both hands.  The patient has a history of alcoholic cirrhosis and was admitted 24 hours ago due to recurrent episodes of hematemesis.  Evaluation revealed acute variceal bleeding for which the patient received endoscopic therapy.  He also received 6 units of packed red blood cells and 4 units of fresh frozen plasma since admission.  The patient reports feelings of anxiety and worsening tingling and numbness around the mouth for the past 2 hours.  He has also had severe muscle spasms of the hands and legs.  Temperature is 37.1 C (98.8 F), blood pressure is 116/68 mm Hg, and pulse is 92/min.  Jugular venous pressure is normal.  The lungs are clear to auscultation and heart sounds are normal.  Abdominal examination reveals moderate ascites with no tenderness.  He has generalized mild muscle weakness and periodic spontaneous twitching in the major muscle groups.  Laboratory studies at the time of admission are as follows:

Hemoglobin level after the transfusions is 8.9 g/dL.  Further diagnostic testing is pending.  Intravenous administration of which of the following is most likely to improve this patient’s current symptoms?

A 64-year-old man comes to the emergency department due to 2 days of nausea, vomiting, and abdominal distension.  The patient has no abdominal pain.  He has hypertension, hypercholesterolemia, coronary artery disease, and congestive heart failure.  The patient also has chronic back pain due to a compression fracture 6 months ago.  Medications include aspirin, oxycodone, furosemide, losartan, vitamin D, calcium gluconate, and simvastatin.  Temperature is 36.7 C (98 F), blood pressure is 130/70 mm Hg, and pulse is 92/min.  The abdomen is distended but soft and nontender.  There is no rebound tenderness or rigidity.  Bowel sounds are decreased.  There is 1+ peripheral edema.  Laboratory results are as follows:

An electrocardiogram (ECG) shows normal sinus rhythm.  Abdominal x-rays show diffuse bowel distension with a gas pattern in the colon and rectum.  Which of the following is the most appropriate next step in management of this patient?

A 45-year-old woman with cirrhosis due to autoimmune hepatitis comes to her hepatologist for routine follow-up.  She has been feeling well and complains only of mild fatigue.  Her medical history is otherwise unremarkable.  Her medications include lactulose, spironolactone, propranolol, and furosemide.  Vital signs are within normal limits.  The remainder of her physical examination is consistent with compensated cirrhosis.  Laboratory results are as follows:

Which of the following is the most appropriate next step in managing this patient’s low serum calcium?

A 62-year-old woman comes to the emergency department due to abnormal laboratory studies.  The patient was recently hospitalized for diabetic foot osteomyelitis.  Surgical débridements were performed, and bone culture grew methicillin-sensitive Staphylococcus aureus, for which she is taking intravenous cefazolin at home.  Today, the patient was found to have an elevated serum creatinine level of 3.2 mg/dL at follow-up.  She reports malaise; nausea; intermittent, nonbilious vomiting; and decreased urine output over the past several days.  Medical history also includes well-controlled hypertension but no prior kidney disease.  Medications include lisinopril, insulin, and metformin.  Temperature is 37.3 C (99.1 F), blood pressure is 154/92 mm Hg, and pulse is 84/min.  Physical examination shows moist mucous membranes, normal jugular venous pressure, clear lungs, normal heart sounds, a nontender abdomen, and 2+ bilateral edema of the lower extremities.  The right foot ulcer is healing well with no surrounding erythema or drainage.  Laboratory studies are as follows:

Which of the following histopathologic changes most likely explains this patient’s acute kidney injury?

A 63-year-old woman comes to the office for an annual examination.  She has had polyuria over the past several weeks but has not had fever, chills, dysuria, suprapubic pain, vomiting, or diarrhea.  The patient has had 2 urinary tract infections during the past year that resolved with outpatient antibiotic therapy.  Medical history is significant for diet-controlled diabetes mellitus and obsessive-compulsive disorder, for which she takes sertraline.  Temperature is 36.9 C (98.5 F), blood pressure is 130/68 mm Hg, pulse is 65/min, and respirations are 14/min.  On physical examination, the patient is alert and oriented.  Mucous membranes are moist.  Cardiopulmonary examination is unremarkable.  The abdomen is soft and nontender.  Neurologic examination is normal.  Laboratory results are as follows:

Which of the following is the best next step in management?

A 42-year-old man is brought to the emergency department 1 hour after the onset of severe headache, nausea, vomiting, and confusion.  The patient has primary hypertension and chronic kidney disease; he has been prescribed 2 antihypertensive agents but has been noncompliant with therapy recently.  Temperature is 36.8 C (98.2 F), blood pressure is 240/150 mm Hg, heart rate is 90/min, and respirations are 20/min.  Ophthalmologic examination shows bilateral papilledema.  The lungs are clear to auscultation.  Cardiac examination reveals an S4 and no murmurs.  Laboratory results are as follows:

Which of the following pathologic findings in the kidney is most correlated with this patient’s acute condition?

A 28-year-old man comes to the clinic for routine follow-up for type 1 diabetes mellitus.  The patient was diagnosed 11 years ago and takes insulin as prescribed.  He has no new concerns since his last visit.  Temperature is 37.1 C (98.8 F), blood pressure is 124/76 mm Hg, and pulse is 72/min.  Physical examination shows no evidence of peripheral neuropathy.  Laboratory results are as follows:

A pharmacotherapeutic agent with which of the following effects would be most helpful in slowing the progression of kidney disease in this patient?

A 53-year-old Caucasian man comes to the office for intermittent generalized headaches 8 months after deceased donor kidney transplantation.  The patient’s post-transplantation course was complicated by an episode of acute rejection at 2 months that was treated effectively with high-dose corticosteroids.  He has diabetes mellitus and hypertension.  His medications include insulin, atenolol, cyclosporine, mycophenolate mofetil, and vitamin D.  No changes were made to his medications recently and his immunosuppressants are at therapeutic levels.  The kidney donor had no personal or family history of hypertension.  The patient’s temperature is 36.1 C (97 F), blood pressure is 180/110 mm Hg, and heart rate is 90/min.  Examination shows no abnormalities.  His serum laboratory values are:

The patient is started on sodium restriction, amlodipine, and enalapril to control the hypertension.  One week later, he returns with a blood pressure of 138/86 mm Hg.  His serum creatinine level is 2.4 mg/dL.  Which of the following is the most likely underlying cause of this patient’s hypertension?

A 54-year-old man comes to the emergency department due to progressively worsening shortness of breath, lower extremity swelling, and decreased urine output for the past week.  Medical history includes heart failure with reduced ejection fraction.  Medications include metoprolol succinate, lisinopril, spironolactone, and furosemide.  The patient has been taking the same doses of these medications for the past 6 months but admits that he “misses some doses now and then.”  Temperature is 36.9 C (98.4 F), blood pressure is 112/64 mm Hg, pulse is 90/min, and respirations are 20/min.  Oxygen saturation is 93% on room air.  Physical examination shows jugular venous distension.  S1 and S2 are normal, and there are no murmurs.  An S3 is heard.  Crackles are heard at the bilateral lung bases.  The abdomen is distended, and there is 2+ pitting lower extremity edema bilaterally.  Laboratory results (current and from 3 weeks ago) are as follows:

Urinalysis is unremarkable.  Which of the following is the most likely cause of this patient’s acute kidney injury?

A 68-year-old hospitalized woman is evaluated for new-onset renal dysfunction after being admitted 5 days ago due to abdominal pain.  Abdominal CT scan with intravenous contrast performed in the emergency department revealed sigmoid diverticulitis with localized microperforation.  The patient was treated nonoperatively with bowel rest and intravenous fluids, ciprofloxacin, and metronidazole.  Symptoms gradually improved, and an oral diet was initiated.  On the fourth hospitalization day, the patient is noted to have worsening renal function.  She has no history of kidney disease and has had no significant hypotension during hospitalization.  Temperature is 37.4 C (99.3 F), blood pressure is 132/80 mm Hg, pulse is 82/min, and respirations are 16/min.  Urine output has been 0.3 mL/kg/hr for the past 12 hours.  Physical examination shows moist mucous membranes, normal jugular venous pressure, clear lungs, and normal heart sounds.  There is mild tenderness of the left lower quadrant to deep palpation.  Laboratory findings are as follows:

Which of the following is the most likely cause of this patient’s kidney injury?

A 62-year-old woman comes to the office due to fatigue and lethargy over the last 6 months.  She has a history of chronic kidney disease due to long-standing type 2 diabetes mellitus and hypertension.  Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, pulse is 84/min, and respirations are 16/min.  There is conjunctival pallor.  The lung fields are clear, and no murmurs are heard on cardiac examination.  The abdomen is nontender.  Test of the stool for occult blood is negative.  Laboratory results are as follows:

Which of the following is the best next step in management of this patient’s anemia?

A 79-year-old woman is brought to the emergency department due to right hip pain and inability to stand after being found on the floor of her home.  She tripped over a rug and fell onto her right side 2 days ago but was unable to get up due to pain.  Medical history is significant for hypertension, hyperlipidemia, and chronic kidney disease due to hypertension.  Medications include losartan and chlorthalidone.  Temperature is 36.7 C (98.1 F), blood pressure is 120/80 mm Hg, and pulse is 105/min.  BMI is 31 kg/m².  On physical examination, the patient is in mild distress due to pain.  Mucous membranes are dry.  The right leg appears shorter than the left and is externally rotated, with ecchymosis over the right lateral thigh.  There is 1+ pitting edema of the bilateral lower extremities.  The lungs are clear to auscultation.  The remainder of the physical examination is normal.  Laboratory results are as follows:

Imaging of the right hip reveals a nondisplaced fracture of the femoral neck.  Surgical hip repair is planned.  Which of the following is the best next step in the diagnosis of this patient’s acute kidney injury?