IMpact: News for Medical Students

Discover your future in Internal Medicine

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.

More About Subspecialty Careers

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.

More About Hospitalist Careers

My Kind of Medicine:
Real Stories of ACP Internists

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

Christine Laine

Dr. Christine Laine

Annals of Internal Medicine Editor

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MKSAP 5 - Question of the Week

A 19-year-old man is evaluated for proteinuria discovered during a routine sports preparticipation evaluation. He has been asymptomatic, has no other medical problems, and takes no medications.

On physical examination, temperature is 36.6°C (97.8°F) blood pressure is 110/72 mm Hg, pulse rate is 60/min, and respiration rate is 12/min. BMI is 18. The funduscopic, cardiopulmonary, and skin findings are normal. No peripheral edema is present.

Hemoglobin 15 mg/dL (150 g/L)
Albumin 4.1 g/dL (41 g/L)
Total cholesterol 130 mg/dL (3.4 mmol/L)
Creatinine 0.7 mg/dL (61.9 µmol/L)
Glucose 92 mg/dL (5.1 mmol/L)
Total protein 6.5 g/dL (65 g/L)
Spot urine protein–creatinine ratio 0.8 mg/mg
Urinalysis Urine dipstick: protein, 2+; blood, negative; glucose, negative. Microscopic: rare hyaline cast, no cells or crystals.

The most appropriate next diagnostic test is to evaluate the patient for orthostatic proteinuria. This is done by obtaining separate upright (daytime) and supine (overnight) urine collections for protein quantitation. Orthostatic proteinuria is defined by an increase in urinary protein excretion only in the upright position; when supine, the urinary protein excretion rate is normal (<50 mg/8 h). The condition is seen most commonly in children or young adults. The total urine protein excretion rate is usually less than 1 g/24 h, and the urinalysis is otherwise normal. The etiology of the condition is uncertain; in some cases, mild alterations in glomerular histology have been reported. An association of orthostatic proteinuria with entrapment of the left renal vein between the aorta and the superior mesenteric artery (“nutcracker syndrome”) also has been reported. The condition is benign; it often resolves spontaneously, and long-term follow-up studies in affected patients have shown renal function remains normal.

A kidney biopsy is not the most appropriate next step in this patient's management. His medical history provides no evidence of significant past or present illness, and his physical examination and initial laboratory studies do not suggest serious kidney disease. Specifically, he is normotensive and not edematous; the serum creatinine, albumin, and cholesterol are normal; and, the urinalysis is normal.

A single 24-hour urine collection would most likely only confirm the subnephrotic rate of urinary protein excretion, which is already evident from the spot urine protein–creatinine ratio of 0.8 mg/mg. More importantly, a single 24-hour urine collection would fail to differentiate the rates of upright versus supine proteinuria, which is essential in distinguishing orthostatic from persistent proteinuria.

Given the patient's age, normal hemoglobin, and serum protein, a dysproteinemia is very unlikely, and serum and urine protein electrophoresis studies are not needed. Should the patient prove to have persistent proteinuria, urine protein electrophoresis and immunofixation studies may be useful in determining whether the proteinuria reflects glomerular or tubular disease.

Key Point

  • Orthostatic proteinuria is defined by an increase in urinary protein excretion only in the upright position.
Q. Which of the following is the most appropriate next diagnostic test?
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Doctor's Dilemma™

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