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The General Internist Career Path

Internal Medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.

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The Subspecialist Career Path

Subspecialists in internal medicine have chosen to receive additional, more in-depth training and board certification in the diagnosis and management of diseases of a specific type or diseases affecting a single organ system.

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The Hospitalist Career Path

Hospitalists are providers who dedicate most of their career to the care of hospitalized patients. They focus on clinical management, with an added eye to quality, safety, and utilization.

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My Kind of Medicine:
Real Stories of ACP Internists

Saad Z. Usmani

Dr. Saad Z. Usmani

Director of Clinical Research

Joshua M. Liao, MD

Dr. Joshua M. Liao

Internal Medicine Resident

Dr. Valerie J. Lang

Dr. Valerie J. Lang

Associate Professor of Medicine

Dr. David Fleming

Dr. David Fleming

ACP President with Dr. Robert Centor, ACP Chair, Board of Regents

Dr. Kent J. DeZee

Dr. Kent DeZee

Program Director, General Medicine Fellowship

Dr. Erik Wallace

Dr. Erik Wallace

Associate Dean

Dr. Suchitra Behl

Dr. Suchitra Behl

Consultant for FORTIS C-DOC

Dr. Aysha Khoury

Dr. Aysha Khoury

Clinical Decision Unit Internist

Victor Simms

Dr. Victor A. Simms

Associate Chief, Dept. of IM

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MKSAP 5 - Question of the Week

A 25-year-old woman is evaluated during a routine follow-up visit. Four months ago, she was diagnosed with systemic lupus erythematosus that manifested as fatigue, malar rash, oral ulcers, pleuritis, and arthralgia. At that time, she began treatment with hydroxychloroquine and a 1-month course of low-dose prednisone.

On physical examination today, she states that her symptoms have resolved somewhat but that she still has slight fatigue and mild arthralgia in her hands, feet, and knees. Temperature is 36.4C (97.6F), blood pressure is 130/92 mm Hg, pulse rate is 84/min, and respiration rate is 18/min. She has a mild malar flush, a painless ulcer on the hard palate, and trace bilateral ankle edema. The remainder of the examination is normal.

Hemoglobin 10 g/dL (100 g/L)
Leukocyte count 2300/L (2.3 109/L)
Platelet count 132,000/L (132 109/L)
Erythrocyte sedimentation rate 45 mm/h
Serum creatinine 1.0 mg/dL (88.4 mol/L)
Albumin 3.1 g/dL (31 g/L)
Serum complement (C3 and C4) Decreased
Urinalysis 2+ protein; 3+ blood; 5-10 leukocytes, 15-20 erythrocytes, and 1 erythrocyte cast/hpf

This patient's hypertension, ankle edema, hematuria, proteinuria, hypoalbuminemia, and erythrocyte casts on urinalysis are highly suggestive of lupus nephritis despite the absence of renal insufficiency. To prevent irreversible renal damage, early treatment with a high-dose corticosteroid such as prednisone is indicated for patients whose condition raises strong suspicion for lupus nephritis. Whether renal biopsy is necessary in this clinical situation in order to establish a diagnosis remains uncertain, and treatment with high-dose corticosteroids would not significantly alter subsequent biopsy results.

Initiation of antihypertensive therapy would benefit this patient but is not the most appropriate next step in the management of her condition; treatment of her nephritis takes precedence and may itself help to control her hypertension. Instead of a calcium channel blocker such as amlodipine, angiotensin-converting enzyme inhibitors are the antihypertensive drugs of choice in patients with lupus nephritis because these agents help to control proteinuria.

Ibuprofen may help to control this patient's arthralgia. However, NSAIDs can significantly worsen renal function in patients with lupus nephritis and are therefore contraindicated in this patient population.

Low-dose prednisone may help to alleviate this patient's arthralgia and rash but would not treat her lupus nephritis.

Key Point

  • Early treatment with high-dose corticosteroids is indicated in patients whose condition raises strong suspicion for lupus nephritis.
Q. Which of the following is the next best step in this patient's treatment?
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