Riddler #8Riddler #8

24 y/o man who formerly used injection 24 y/o man who formerly used injection drugs is found to have a blood urea drugs is found to have a blood urea nitrogen concentration of 24mg/dl, a nitrogen concentration of 24mg/dl, a serum creatinine concentration of 2.5 serum creatinine concentration of 2.5 mg/dL, and a urine protein-to-creatinine mg/dL, and a urine protein-to-creatinine ratio of 8. Tests are positive for HIV and ratio of 8. Tests are positive for HIV and negative for Hep b and C. Renal U/S negative for Hep b and C. Renal U/S shows kidneys of 11cm on Right and shows kidneys of 11cm on Right and 10.5 on left. Renal biopsy is performed.10.5 on left. Renal biopsy is performed.

8 con’t8 con’t

What is the most likely pattern of What is the most likely pattern of glomerular injury in this patient? (2pts)glomerular injury in this patient? (2pts)

A) Minimal change diseaseA) Minimal change disease B) Membranous glomerulopathyB) Membranous glomerulopathy C) Membranoproliferative C) Membranoproliferative

glomerulonephritisglomerulonephritis D) Allergic Interstitial NephritisD) Allergic Interstitial Nephritis E) Collapsing focal and segmental E) Collapsing focal and segmental

glomerulonephritisglomerulonephritis

Riddler #8 answerRiddler #8 answer

E) HIV nephropathy with collapsing focal and E) HIV nephropathy with collapsing focal and segmental glomerulosclerosis, manifested by segmental glomerulosclerosis, manifested by nephritic-range proteinuria, azotemia and nephritic-range proteinuria, azotemia and normal sized kidneys.normal sized kidneys.

Minimal change disease is the most common Minimal change disease is the most common nephrotic syndrome in kids, rare in HIV patients.nephrotic syndrome in kids, rare in HIV patients.

Membranous nephropathy is sometimes assoc Membranous nephropathy is sometimes assoc with hep b, gold, sle, nsaids, less so with hep cwith hep b, gold, sle, nsaids, less so with hep c

Membranoproliferative glomerulonephritis type 1 Membranoproliferative glomerulonephritis type 1 hep C and HIV, endocarditis. Type 2 seen after hep C and HIV, endocarditis. Type 2 seen after renal transplant, Type 3 similar to type 1.renal transplant, Type 3 similar to type 1.

#8 con’t#8 con’t

Allergic interstitial nephritis Allergic interstitial nephritis usually does not cause nephritic usually does not cause nephritic range proteinuriarange proteinuria

Riddler #9Riddler #9

A 76 y/o woman is admitted with 3 A 76 y/o woman is admitted with 3 hours of crushing substernal chest pain. hours of crushing substernal chest pain. PMH of PVD (Left carotid occlusion with PMH of PVD (Left carotid occlusion with hemiparesis 3 months ago), HTN, HLD, hemiparesis 3 months ago), HTN, HLD, and DM complicated by neuropathy and and DM complicated by neuropathy and retinopathy. BP 120/70, hr 120, sat 92% retinopathy. BP 120/70, hr 120, sat 92% on RA, S3 and JVD on exam. Meds on RA, S3 and JVD on exam. Meds include warfarin 5mg; atenolol 25mg; include warfarin 5mg; atenolol 25mg; pravastatin 20. EKG with 3mm ST- pravastatin 20. EKG with 3mm ST- Segment elevation in V2-6. INR 1.8Segment elevation in V2-6. INR 1.8

Riddler #9Riddler #9

What medications can you give her in What medications can you give her in the ED to lower her mortality risk? 3ptthe ED to lower her mortality risk? 3pt

Would you give thrombolytics if the Would you give thrombolytics if the cath lab will not be available for at cath lab will not be available for at least 2 hours? why or why not? 3ptsleast 2 hours? why or why not? 3pts

Assuming that this patient was Assuming that this patient was reperfused within 4 hours what is her reperfused within 4 hours what is her 30 day mortality risk? (be as specific 30 day mortality risk? (be as specific as possible) 5ptsas possible) 5pts