Renal azotemia Quiz: Ace Your Exams

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A 50-year-old woman comes to the emergency department for evaluation of right-sided flank pain and dark urine for the past few hours. The patient states, “I thought my back was acting up again so I took two extra naproxen today. I decided to come get checked out once my urine appeared dark.” The patient denies dysuria, urinary frequency, urgency, fever or chills. Past medical history includes type 2 diabetes mellitus, chronic lumbosacral back pain and migraine headaches. Current medications include phenacetin, acetaminophen, ibuprofen, naproxen and insulin. Temperature is 37.1°C (98.8° F), pulse is 85/min, respirations are 21/min, and blood pressure is 130/70 mm Hg. Serum creatinine is 1.9 mg/dL (reference range: 0.6-1.2 mg/dL). Urinalysis is shown.

 Laboratory value  Result  Reference range 
 Urinalysis  
 Color  Clear  Yellow 
 Specific gravity  1.013  1.005-1.030 
 Protein  1 g/day  <150 mg/day 
 Blood  Positive  Negative 
 Leukocyte esterase  Negative  Negative 
 Leukocytes  1-2/hpf  0-5/hpf 
 Erythrocytes  40-42/hpf  0-4/hpf 
 Dysmorphic RBCs  None  None 
 Casts  None  None 


Which of the following is the most likely etiology of this patient’s hematuria?

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