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Case
A 62-year-old woman is being treated for chronic congestive heart failure. She has been
put on hydrochlorothiazide therapy. Her serum electrolyte levels are being monitored
and show a persistent hypokalemia.
Question
The addition of what to her therapeutic regimen would be most appropriate?
Correct Answer: Correct Answer:
Amiloride
Explanation
Amiloride is a potassium-sparing diuretic. Its diuretic effect is not very potent; therefore,
it is good to use in combination with other diuretics.
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Acetazolamide is a carbonic anhydrase inhibitor. It causes a mild diuresis, a marked
elevation of urinary pH, and a significant loss of potassium.
Furosemide is a loop diuretic. It has a rapid onset of action and is a potent diuretic.
However, it also causes potassium depletion and would only worsen the hypokalemia.
Indapamide is a thiazide analog with a long duration of action. If anything, it would
exacerbate the hypokalemia.
Mannitol is an osmotic diuretic and would not be recommended in this patient.
Furthermore, it would not have a potassium-sparing effect.
Case
A 42-year-old man presents with lower extremity swelling. His past medical history and
review of symptoms is otherwise negative. The patient looks comfortable, with vitals
showing the following: BP 142/91 mm Hg, HR 90 beats/min, RR 16 breaths/min, T 98°F,
height 5'9'', and weight 158 lb. His examination is only remarkable for 2+ pitting edema
in the lower extremities. The patient is counseled on a low-salt diet. The abnormal
laboratory values are as follows:
Lab Result
Urinalysis 3+ protein, coarse granular casts, 2 - 5 WBCs, 0 - 2 RBCs
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Serum albumin 2.1 gm/dL
Serum creatinine 2.0 mg/dL
Serum BUN 18 mg/dL
Hemoglobin 12.1 gm/dL
Question
What should be the next step in the management of this patient?
Correct Answer: Correct Answer:
Order a 24-hour urine to quantitate urine protein
Explanation
The clinical picture is most consistent with nephrotic syndrome. This syndrome is
characterized by proteinuria in excess of 3.5 grams a day per 1.73 m3 body surface
area. Other symptoms commonly seen include edema, hypoalbuminemia, and
hyperlipidemia. Patients may also exhibit anemia. Usually there is not an active urine
sediment. The correct diagnostic test to confirm nephrotic syndrome is a 24-hour urine
to quantitate the protein loss.
If the diagnosis is confirmed, a renal biopsy may be considered to aid in determining the
cause of nephrotic syndrome. However, because it is an invasive test, it should not be
performed until the diagnosis is established.
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The patient has no symptoms of a urinary tract infection and only a small number of
WBCs in her urinalysis, so a urine culture and empiric treatment would not be indicated.
Since the patient does not have hematuria or pain, a kidney stone is unlikely; therefore,
an intravenous pyelogram would not be indicated.
Case
A 54-year-old man presents with a lump in his scrotum recently. After answering many
questions about possible symptoms and undergoing a thorough genitourinary
examination, the patient is told that he most likely has a hydrocele.
Question
What findings most closely support this diagnosis?
Correct Answer: orrect answer:
Non-tender, fluid-filled lesion that transilluminates
Explanation The correct answer is a non-tender, fluid-filled lesion that transilluminates.
A hydrocele is a collection of fluid within the tunica vaginalis. It is non-tender, usually
develops slowly over time, and will transilluminate when a light is held up to the scrotal
wall. Patients can experience fluctuating size of the hydrocele, swelling of the scrotum
or inguinal canal, heavy sensation within the scrotum, and do not typically experience
any pain.
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A+
Case
A 62-year-old woman is being treated for chronic congestive heart failure. She has been
put on hydrochlorothiazide therapy. Her serum electrolyte levels are being monitored
and show a persistent hypokalemia.
Question
The addition of what to her therapeutic regimen would be most appropriate?
Correct Answer: Correct Answer:
Amiloride
Explanation
Amiloride is a potassium-sparing diuretic. Its diuretic effect is not very potent; therefore,
it is good to use in combination with other diuretics.
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Acetazolamide is a carbonic anhydrase inhibitor. It causes a mild diuresis, a marked
elevation of urinary pH, and a significant loss of potassium.
Furosemide is a loop diuretic. It has a rapid onset of action and is a potent diuretic.
However, it also causes potassium depletion and would only worsen the hypokalemia.
Indapamide is a thiazide analog with a long duration of action. If anything, it would
exacerbate the hypokalemia.
Mannitol is an osmotic diuretic and would not be recommended in this patient.
Furthermore, it would not have a potassium-sparing effect.
Case
A 42-year-old man presents with lower extremity swelling. His past medical history and
review of symptoms is otherwise negative. The patient looks comfortable, with vitals
showing the following: BP 142/91 mm Hg, HR 90 beats/min, RR 16 breaths/min, T 98°F,
height 5'9'', and weight 158 lb. His examination is only remarkable for 2+ pitting edema
in the lower extremities. The patient is counseled on a low-salt diet. The abnormal
laboratory values are as follows:
Lab Result
Urinalysis 3+ protein, coarse granular casts, 2 - 5 WBCs, 0 - 2 RBCs
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Serum albumin 2.1 gm/dL
Serum creatinine 2.0 mg/dL
Serum BUN 18 mg/dL
Hemoglobin 12.1 gm/dL
Question
What should be the next step in the management of this patient?
Correct Answer: Correct Answer:
Order a 24-hour urine to quantitate urine protein
Explanation
The clinical picture is most consistent with nephrotic syndrome. This syndrome is
characterized by proteinuria in excess of 3.5 grams a day per 1.73 m3 body surface
area. Other symptoms commonly seen include edema, hypoalbuminemia, and
hyperlipidemia. Patients may also exhibit anemia. Usually there is not an active urine
sediment. The correct diagnostic test to confirm nephrotic syndrome is a 24-hour urine
to quantitate the protein loss.
If the diagnosis is confirmed, a renal biopsy may be considered to aid in determining the
cause of nephrotic syndrome. However, because it is an invasive test, it should not be
performed until the diagnosis is established.
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The patient has no symptoms of a urinary tract infection and only a small number of
WBCs in her urinalysis, so a urine culture and empiric treatment would not be indicated.
Since the patient does not have hematuria or pain, a kidney stone is unlikely; therefore,
an intravenous pyelogram would not be indicated.
Case
A 54-year-old man presents with a lump in his scrotum recently. After answering many
questions about possible symptoms and undergoing a thorough genitourinary
examination, the patient is told that he most likely has a hydrocele.
Question
What findings most closely support this diagnosis?
Correct Answer: orrect answer:
Non-tender, fluid-filled lesion that transilluminates
Explanation The correct answer is a non-tender, fluid-filled lesion that transilluminates.
A hydrocele is a collection of fluid within the tunica vaginalis. It is non-tender, usually
develops slowly over time, and will transilluminate when a light is held up to the scrotal
wall. Patients can experience fluctuating size of the hydrocele, swelling of the scrotum
or inguinal canal, heavy sensation within the scrotum, and do not typically experience
any pain.
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