A 62-year-old male comes to your primary care office with shortness of breath that has progressively worsened over the last three weeks. His medical history is significant for hypertension, diabetes and knee pains. He takes ibuprofen for his knee pains, he reports, ‘Without it, I can’t function’. He started on hydrochlorothiazide 6 months ago. Two months later, his doctor added one more ‘blue pill’ to control his blood pressure because the first pill was not completely effective. He can’t remember the name of the ‘blue pill’. Last month, he was started on a third pill because the first two medications could not bring his blood pressure to a normal level. His current medications are hydrochlorothiazide 25 mg, a blue pill, lisinopril 20 mg, insulin of unknown units per day and ibuprofen 800 mg three times a day. His temperature is 99 ⁰ F, heart rate is 62 beats per minute, respiratory rate is 17 breaths per minute, and blood pressure is 165/95 mm Hg. Physical examination reveals an anxious patient; on auscultation fine crackles at the bases of the lungs, audible bruit on both sides of his abdomen, and bilateral pitting edema. Laboratory tests show elevated serum creatinine, elevated renin, and hypokalemia. Chest x-ray shows increased interstitial markings, butterfly pattern of distribution of alveolar thickening, and increased blurriness of vascular outlines. Abdominal ultrasound revealed two small hyperechoic kidneys. What is the next best step in the management of this patient?

A 44-year-old woman presents to the gynecology clinic with complaints of involuntary urine leakage over the past year. She notices leakage when she coughs, sneezes, laughs, or engages in physical activities such as jogging. She denies any urinary urgency, frequency, nocturia, or pain. She drinks 3 cups of coffee daily. The condition has started affecting her confidence, leading to avoidance of social gatherings and exercise. Her past medical history is significant for urethral stricture, kidney stones and urinary tract infection, all successfully treated at the time of diagnosis. The patient has a history of three vaginal deliveries, with no significant complications. She is otherwise healthy, with no history of urinary tract infections or pelvic surgery. Her weight is 85 kg, with a BMI of 30. Pelvic Exam reveals mild anterior vaginal wall laxity but no significant pelvic organ prolapse. Urine leakage is observed during a cough with a moderately full bladder. Post-Void Residual (PVR): Measured via ultrasound and is within normal limits, ruling out urinary retention. Which factor is most commonly associated with an increased risk of this type of urinary incontinence?

A 43-year-old woman presents to the gynecology clinic with complaints of involuntary urine leakage over the past year. She notices leakage when she coughs, sneezes, laughs, or engages in physical activities such as jogging. She denies any urinary urgency, frequency, nocturia, or pain. The condition has started affecting her confidence, leading to avoidance of social gatherings and exercise. The patient has a history of three vaginal deliveries, with no significant complications. She is otherwise healthy, with no history of urinary tract infections or pelvic surgery. Her weight is 85 kg, with a BMI of 30. Pelvic Exam reveals mild anterior vaginal wall laxity but no significant pelvic organ prolapse. Urine leakage is observed during a cough with a moderately full bladder. Post-Void Residual (PVR): Measured via ultrasound and is within normal limits, ruling out urinary retention. Which of the following is a first-line treatment for this patient’s incontinence?

A 42-year-old woman presents to the gynecology clinic with complaints of involuntary urine leakage over the past year. She notices leakage when she coughs, sneezes, laughs, or engages in physical activities such as jogging. She denies any urinary urgency, frequency, nocturia, or pain. The condition has started affecting her confidence, leading to avoidance of social gatherings and exercise. The patient has a history of three vaginal deliveries, with no significant complications. She is otherwise healthy, with no history of urinary tract infections or pelvic surgery. Her weight is 85 kg, with a BMI of 30. Pelvic Exam reveals mild anterior vaginal wall laxity but no significant pelvic organ prolapse. Urine leakage is observed during a cough with a moderately full bladder. Post-Void Residual (PVR) is measured via ultrasound and is within normal limits. What is the primary cause of this patient’s incontinence?

A 68-year-old man presents to the emergency department with severe abdominal pain, headache, chest pain, and shortness of breath for the past three days. He has a history of coronary artery disease, asthma, and resistant hypertension diagnosed three months ago. Over the last month, his GFR has rapidly declined. On examination, his blood pressure is 210/115 mmHg, and he has diffuse pulmonary crackles bilaterally. An abdominal bruit is noted on the left side. A chest X-ray shows bilateral fluffy pulmonary infiltrates. Renal artery stenosis is suspected, and renal ultrasound confirms 89% stenosis in the left renal artery and 74% stenosis in the right renal artery. What is the most appropriate next step in management?