Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 56-year-old man is evaluated for painless intermittent bloody urine of 6 weeks’ duration. History is significant for granulomatosis with polyangiitis (formerly known as Wegener granulomatosis) diagnosed 10 years ago, which is now in remission; he was treated with prednisone for 3 years and oral cyclophosphamide for 1 year. He also has hypertension and hyperlipidemia. Current medications are metoprolol and atorvastatin.
On physical examination, temperature is 36.7 °C (98.0 °F), blood pressure is 146/94 mm Hg, pulse rate is 68/min, and respiration rate is 14/min. BMI is 28. There are no rashes or ulcers. Genitalia are normal. The remainder of the examination, including cardiopulmonary examination, is normal.
Laboratory studies:
| Chemistry panel and kidney function tests | Normal |
| Hemoglobin | 12.1 g/dL (121 g/L) |
| Erythrocyte sedimentation rate | 35 mm/h |
| p-ANCA | Negative |
| Antimyeloperoxidase antibodies | Negative |
| Antiproteinase 3 antibodies | Negative |
| Urinalysis | Trace protein; 10-20 erythrocytes/hpf; 0-2 leukocytes/hpf; no casts |
| Urine cultures | Negative |
A chest radiograph is normal.
Which of the following is the most appropriate diagnostic test to perform next?
A. CT of the abdomen and pelvis with contrast
B. Cystoscopy
C. Kidney and bladder ultrasonography
D. Urine eosinophil measurement
E. Urine protein-creatinine ratio
Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.
