Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 77-year-old woman is evaluated 4 months following a left middle cerebral artery ischemic stroke. The severity of her stroke required prolonged initial hospitalization and a 3-month stay in a rehabilitation center before returning home. Residual deficits include dense right-sided hemiparesis and dysphagia requiring oral feeding with thickened liquids. Medical history is otherwise significant for hypertension and diabetes mellitus. Current medications are aspirin, chlorthalidone, lisinopril, tolterodine, and insulin.
On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 136/86 mm Hg, and pulse rate is 86/min. BMI is 18. The general medical examination is unremarkable. Neurologic examination reveals dysarthria, left-sided facial droop, 1/5 strength in the right arm and leg, and bilateral distal sensory neuropathy.
Laboratory studies:
| Hemoglobin A1c | 7.2% |
| Albumin | 2.4 g/dL (24 g/L) |
| Blood urea nitrogen | 12 mg/dL (4.3 mmol/L) (4 months ago: 28 mg/dL [10 mmol/L]) |
| Creatinine | 0.8 mg/dL (70.7 µmol/L) (4 months ago: 1.4 mg/dL [123.8 µmol/L]) |
| Urinalysis | Normal |
Which of the following is the most likely cause of this patient’s decreased serum creatinine level?
A: Decrease in muscle mass
B: Improvement in diabetic kidney disease
C: Initiation of chlorthalidone
D: Initiation of lisinopril
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