Question of the Week # 43

A 55 y/o woman with history of well controlled DM Type II presents for her regular follow-up visit. She has no new complaints. She has been well controlled on Metformin alone with a hemoglobin A1c of 6.5. The patient is afebrile with a B.P 96/72, HR 88, RR 16. Physical examination is benign except for decreased sensation in her bilateral lower extremities consistent with diabetic neuropathy and bilater lower extremity edema. Her last urinary microalbumin about one year ago was negative. A repeat dipstick test now is positive for protein and blood but negative for leucoesterase and nitrite. Subsequent urine microscopy reveals 4 dysmorphic RBCs/HPF and red cell casts. Labs reveal elevated serum creatinine at 1.4 as opposed to her baseline creatinine of 0.8 6 months ago. The next important step in approaching this patient’s Renal Insufficiency is:

A) Obtain CPK level
B) 24 hour urine for microalbumin
C) Start ACE inhibitor
D) Repeat urinalysis in 3 months
E) Referral to Nephrologist and Renal biopsy
F) Start emperic antibiotic therapy for UTI

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