A 66-Year-Old Man Comes to the Office for a Follow-Up

question 706

Multiple Choice

A 66-year-old man comes to the office for a follow-up visit.  The patient was hospitalized 3 months ago for an upper gastrointestinal bleed.  A duodenal ulcer with oozing hemorrhage was found on endoscopy and treated with thermal coagulation.  Testing for infection with Helicobacter pylori was negative.  The patient had taken nonsteroidal anti-inflammatory drugs frequently before the bleed but no longer uses them.  His hemoglobin at discharge was 9.2 g/dL.  Since this hospitalization, the patient has not noticed any melena, hematochezia, lightheadedness, changes in urine appearance or output, or abdominal pain.  However, over the last 3 days, he has developed subjective fever, nausea, and malaise.  Other review of systems is negative.  The patient's other medical history includes hypertension, chronic kidney disease (baseline creatinine 1.3-1.5 g/dL) , osteoarthritis, and hyperlipidemia.  Medications include lisinopril, amlodipine, carvedilol, omeprazole, and atorvastatin.  He has no known drug allergies.
Temperature is 38.1 C (100.6 F) , blood pressure is 142/82 mm Hg, pulse is 85/min, and respirations are 16/min.  Examination shows moist mucous membranes, no jugular venous distension, normal breath sounds, and no peripheral edema.  The patient's abdomen is soft and nontender.  Laboratory results are as follows:
Which of the following is the most appropriate next step in management of this patient?

• A)Discontinue omeprazole
• B)Obtain kidney biopsy
• C)Order urine protein electrophoresis
• D)Send urine eosinophil testing
• E)Start oral prednisone

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