26-year-old man is found to have IgA nephropathy on a renal biopsy performed for intermittent hematuria and persistent proteinuria(UPC 1.8). His serum creatinine is 1.2 mg/dl. UPC declines to 1.5 and the serum creatinine increases to 1.3 mg/dl after 3 months of lisinopril 10 mg/d. The urinary Na excretion is 180 mmol/d. Which ONE of the following should be done next?

Correct Answer: D

Rationale: High sodium intake can reduce the effectiveness of ACE inhibitors like lisinopril. A low-sodium diet will enhance the drug's efficacy thus reducing proteinuria and protecting renal function.

Correct Answer: B

Rationale: Left-sided heart failure is most often associated with left-ventricular infarction and systemic hypertension. The ineffective pumping of the left ventricle results in an accumulation of blood within the pulmonary circulation. As a result, pulmonary congestion with dyspnea is an expected finding. Jugular vein distention is more often associated with right-sided failure. Peripheral edema is associated with right-sided failure. Hepatomegaly is not seen in pure left-sided edema.

Correct Answer: B

Rationale: BNP (B-type natriuretic peptide) of 820 is elevated, confirming heart failure as it indicates cardiac stress and fluid overload, aligning with the symptoms described.

Correct Answer: D

Rationale: Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

Correct Answer: D

Rationale: The first heart sound ('lub') occurs when the tricuspid and bicuspid (mitral) valves close at the start of ventricular systole.