A 45-year-old man with a history of chronic hepatitis C infection presents with severe upper gastrointestinal bleeding. Intravenous fluids and packed red blood cells are administered; however, the patient becomes oliguric. Laboratory values reveal a BUN of 62 mg/dL and a creatinine of 4.2 mg/dL. His BUN and creatinine values at a previous appointment 3 months ago were 21 mg/dL and 1.8 mg/dL, respectively.
Which of the following is the definitive treatment of choice for this patient’s condition?
Liver transplantation. This patient is presenting with hepatorenal syndrome, a life-threatening medical condition that involves rapid deterioration in kidney function in patients with cirrhosis. (C, D) Although renal function can sometimes be improved by administration of albumin and systemic vasoconstrictors (midodrine), hepatorenal syndrome is usually fatal unless a liver transplantation is performed. (A) This is the treatment of hepatitis C; however, this patient has progressed to irreversible end stage liver disease. (E) If the patient had prerenal AKI, he might respond to IV fluids; however, he had an elevated creatinine at a previous appointment and therefore likely has chronic renal failure from hepatorenal syndrome.
A 36-year-old woman presents to the clinic with fever and cough. A thorough history is taken, which is notable for night sweats and weight loss over the past 3 months. She was born in Mexico and moved to the United States when she was 31 years old. She denies using any tobacco, alcohol, or illicit drugs. Her laboratory values are notable for a hemoglobin of 10.1 g/dL, and a chest x-ray shows a right upper lobe infiltrate with cavitation.
What is the most important treatment at this time?
Rifampin, isoniazid, pyrazinamide, pyridoxine, and ethambutol. This patient’s symptoms, as well as her risk factor (immigration from an endemic country), make TB a concerning diagnosis. Though an AFB smear and culture should be performed to confirm the diagnosis, she should begin a four-drug therapy for 2 months followed by a two-drug therapy (rifampin and isoniazid) for 4 months. (C) Pyridoxine (vitamin B6) should be given to prevent peripheral neuropathy from isoniazid. (B) Treatment with isoniazid and pyridoxine alone is an option for the treatment of latent TB, as opposed to active TB, which is the diagnosis in this case. (A) Voriconazole is a treatment option for Aspergillus (not fluconazole, which does not have activity against Aspergillus); however, TB is the more likely diagnosis in this case given her risk factors. (E) Levofloxacin can be used as empiric treatment for community-acquired pneumonia.
A 39-year-old man falls off a sailboat and is found much later floating face down in a lake. He is pulled from the water and efforts are made to resuscitate him. A pulse is regained in the ambulance, but he experiences a seizure during transport to the hospital.
What electrolyte abnormality is most likely responsible for this occurrence?
Hyperkalemia. Prolonged water immersion can induce hypothermia in patients, which can lead to rhabdomyolysis and subsequent release of large amounts of potassium from muscle cells. Prolonged vasoconstriction from shivering and hypoxia may also contribute. (D) Hypokalemia is not associated with seizures and is most commonly due to gastrointestinal or renal losses. (B, E) While both hypernatremia and hyponatremia may cause neurologic symptoms such as seizures, they are not associated with hypothermia. (C) Hypercalcemia is associated with nephrolithiasis, abdominal pain, bone wasting, and psychiatric symptoms, but does not commonly cause seizures; hypocalcemia may present with paresthesia.
A 22-year-old woman presents to the office complaining of episodes where her fingers become painful and change color. Her fingers first become cold and pale, then turn blue, and after warming them her fingers become red. She brings in a picture to illustrate what it looks like (Figure below).
She states that this commonly occurs when she shops in the frozen section at a supermarket. She has tried to wear gloves to keep her hands warm but this has not reduced the occurrences of her symptoms. She denies any numbness or weakness of her arms or legs. On examination she has several small ulcerations at the tips of her fingers, with strong pulses present.
What is the best treatment for this patient?
Nifedipine. This patient presents with Raynaud phenomenon, which follows the chronologic color pattern of white to blue to red during episodes. Initial treatment includes avoidance of triggers and measures to maintain warmth of the affected areas, but this patient has failed these treatments. The first-line pharmacologic therapy is the dihydropyridine calcium channel blockers such as nifedipine. (C, D) Sildenafil or prazosin may be considered in patients who are intolerant of calcium-channel blockers. (A) Corticosteroids are used in the treatment of many autoimmune conditions that are associated with Raynaud phenomenon, but should not be used solely to treat Raynaud phenomenon. (E) Without treatment, ischemic episodes may progress to necrosis requiring amputation of a digit.
A 36-year-old man comes to the office for a routine visit. He has not seen a doctor in over 15 years, but his wife insisted he go for a “checkup.” He has no medical problems or complaints. He has smoked half a pack of cigarettes for the last 10 years. His vitals show a temperature of 37.2°C, blood pressure of 148/82 mmHg, heart rate of 70 beats per minute, and respiratory rate of 12 breaths per minute. His BMI is 28 kg/m2 . Repeat blood pressure measurement shows 152/88 mmHg. His physical examination is unremarkable. His laboratory values are shown below.
He is counseled on maintaining a healthy diet, exercise, and smoking cessation.
What is the best next step in management?
Recheck blood pressure in 2 weeks. Hypertension cannot be diagnosed in a single office visit, as the diagnosis of hypertension should be confirmed on three separate visits prior to the initiation of pharmacologic therapy unless the blood pressure elevation is moderate to severe. The best answer is to have the patient return in 2 weeks, at which time his blood pressure can be checked again. Given his age, he should also have a lipid panel performed. (A, B) It is inappropriate to initiate medication before the diagnosis is confirmed. (C) An ECG is not recommended at this time. (E) The patient has an elevated blood pressure, and if left untreated, may produce eventual end-organ damage.
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