History of Present Illness A 28 year old, South Asian male, presents to your clinic with progressively worsening fatigue, joint pain, and headache for three months. During your interview, you learn he has had unexplained fevers, frothy urine and exercise intolerance. A friend who has accompanied his visit expresses that he had a unique rash that resembled a butterfly across his face about two or three months ago. The patient laughs it off from being in the sun, saying it lasted for a day or so. Additionally, he expressed that his finger tips turn white when he washes dishes with cold water. He denies anything making his discomforts better or worse. Past Medical History No PMH Medications None reported Social History The friend believes the patient has been under unusual stress from his new project management job. The patient agrees and confides that he has been anxious and unhappy with his new job, and his unknown medical problems are exacerbating his poor mental health. Physical Examination VITAL SIGNS: Temperature 99.8, pulse 84, respirations 18, blood pressure 152/90, room air pulse ox 96%. HEENT: sclera red/irritated, mucosa membranes dry, PERRLA. Oropharynx clear. Conjunctivae appear well perfused. CHEST: Chest wall is non tender. HEART: Regular rate and rhythm without murmurs. LUNGS: Clear to auscultation bilaterally, equal chest rise, non-labored. ABDOMEN: Soft, positive bowel sounds, non tender. SKIN: No rash/excessive bruising. Petechiae noted in scalp and base of neck. EXTREMITIES: Edema noted in ankles. Positive raynaud syndrome after exposing hands to cups of ice. Painful ROM of elbows and shoulders. NEUROLOGIC: No abnormalities LABS Urinalysis: indicated proteinuria and infiltrate. Abnormal blood tests: antinuclear antibody (1:146), WBC (3.5), RBC (3.7), HGB (10), HCT (30), eGFR (46), ESR (103). Treatment is aimed to reduce kidney inflammation and decrease immune system activity. This is accomplished through medication and diet. Medicines that may be prescribed are: Corticosteroids – these medications, such as prednisone, suppress inflammation Immunosuppressant – immunosuppressive drugs inhibit immune system activity ACE Inhibitors – ACE Inhibitors reduce blood pressure by blocking ACE from converting angiotensin I to angiotensin II. By blocking ACE you also stop the hydrolysis of bradykinin, increasing available bradykinin, which is a vasodilator. Diuretics – There are many types of diuretics, working on various mechanisms. A commonly prescribed diuretic is hydrochlorothiazide. This one in particular inhibits sodium chloride transport in the distal convoluted tubule. More sodium is excreted in the kidney with accompanying fluid. It is not understood, but long term use of HCTZ causes peripheral vasodilation. 1. What is the mechanism of exercise intolerance? 2. Why are ACE inhibitors, ARBs, and diuretics renal protective? 3. What is happening when someone is passing protein in their urine? 4. What is occurring when someone has Raynaud`s Syndrome? 5. What tell-tale S&S give the disease away?