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| Case 1. Mrs. Smith brings 4 year-old Mary into your office and tells you that Mary is wetting her panties during the daytime. She has been toilet trained for over two years and this has never happened before. She fusses when she urinates and the urine has a strong smell. She has a stiff stool every 1-2 days.
Vital signs: 100.8 F, HR 100, RR 38, BP 90/65 PE - No edema, HEENT WNL, chest clear, heart WNL, abdomen soft, non-tender, CVA non-tender, genitalia pre-pubertal female, moderate erythema of the labia, no exudate, hymen intact. UA - Straw Clear pH 8 S.G. 1.020 +1 Blood +30 Alb + LE + Nitrites Micro - 20-30 WBC 10-15 RBC rare WBC clump rare Epi ++ bacteria |
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| Case 2. Mrs. Jones brings 8 year-old John in for his pre-school physical and shots. He likes to drink milk and has a varied diet. He takes chewable multivitamins daily. Mother is worried about his bones, as he had a greenstick fracture of the radius in the spring, so she gives him some "bone supplements" from the health food store. He says his urine is "hot".
PE - HEENT, Chest, Heart, Abd, Genitalia - all completely WNL UA - pH 6.5 S.G. 1.020 +1 Blood +30 Alb - LE - Nitrites Micro - 3-5 WBC 20-40 RBC No casts No bacteria Urine calcium/creatinine ratio 0.42 24 hr urine calcium 5.7 mg/kg/24 hr |
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| Case 3. Mr. and Mrs. Evans bring their 6 year-old son, Bill, to the ER because he has blood in his urine. Ten days previously, his younger brother had a strep throat. Bill was mildly ill only for one day, did not miss school, and did not come to the office. He now has malaise and crampy abdominal pains. He is edematous and pallid.
Vital Signs - BP 140/105 HR 100 RR 42 Temp 99 F PE - +1 periorbital edema trace pre-tibial edema 'full' but not distended abdomen Chest exam is clear. Precordium is active with a systolic flow murmur. UA - cola-colored pH 6.5 S.G. 1.015 ++++ Blood +++ (+300) Alb + LE - Nitrite Micro - TNTC RBC 20-30 WBC 0 Bacteria Occ hyaline Occ cellular cast |
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| Case 4. Mrs. Doe brings 11 year-old Jane to the office because she is losing weight. Jane has had menarche and is concerned with her enlarging breast buds but denies any attempt to diet. She has not been vomiting and stools are 'normal' and daily. She has had sores in her mouth and noted 'sunburn' on her cheeks after a birthday picnic on her grandparent's farm. She has complained about some soreness in her fingers, knees, and elbows.
Chest, Heart, Abd WNL Mild erythema and capillary injection of cheeks with some scale and ulceration Tenderness of knees, elbows, fingers w/ mild edema of PIP joints Vital Signs - Temp 99 BP 107/60 HR 100 RR 21 UA - clear yellow pH 6.5 S.G. 1.015 ++ Blood ++ Alb (+100) + LE - Nitrite Micro - 20-30 RBC 10-15 WBC +1 Epi Tr bacteria Occ hyaline Occ granular cast Labs - ANA 1:1240 C3 15 (30-115) Urinary protein/creatinine ratio 0.860 (<0..150) |
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| Case 5. Mrs. Wilson brings in Laura, 10 years old, for evaluation of abdominal pain. Laura had a seizure 1 year ago and is maintained on carbamazapine. She has significant Right abdominal and flank pain, but the abdomen is soft and is NOT tender to palpation. There is a suggestion of pain with punch over the R CVA region.
Vital Signs - Temp 99 BP 120/72 HR 100 RR 24 UA - Pink, hazy S.G. 1.015 pH 6.5 ++++Blood ++ LE + Alb - Nitrite Micro - TNTC RBC 20-40 WBC No casts Tr bacteria Renal ultrasound: 2 cysts in the right kidney and one solid rounded mass. Cranial CT shows angiomyofibromas. |
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| Case 6. Mrs. Smith brings in her 2 year-old, Mike, whom she says is having an allergic reaction. He had a few bites of seafood at a luncheon 2 days ago, and he woke up this AM with marked swelling og the face and tight, swollen legs. He has gained 2 pounds since his 2 year check-up just 6 weeks ago. He has never had a UA before. He has loose, mucoid stools without blood.
He has edema with ascites, ++ pitting pre-tibial edema, + peri-orbital edema. There is no rash and his joints are normal. Vital Signs - Temp 99 BP 90/58 RR 40 HR 100 UA - Amber clear pH 6.5 S.G. 1.030 + Blood ++++(+1000) Alb - LE - Nitrite Micro - Rare WBC 5-7 RBC +1 Hyaline casts Tr Bact +1 Epi Urine protein/creatinine ratio 3.7 Serum albumin 1.4 |
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| Case 7. Mrs Adams brings in 5 month-old Joseph and one of his diapers, which she says has blood in it. He is apparently healthy, but this was found after his afternoon nap. You place a U-bag on him and await urine.
PE - He moves all extremities well, and has a normal exam of the genitalia, chest, heart, and abdomen Vital Signs - Temp 99 HR 100 RR 30 BP 86/60 The diaper has a definite reddish area, which is anterior and wet. You apply a urine dipstick but the Heme area does not change color. He voids and the urine in the bag is bright orange-red in color. You centrifuge the urine and examine the sediment and supernatant. You question the mother about the infant's diet. |
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| Case 8. Mrs. Jones brings in Ed, 8 years-old, for his physical. You find him to be healthy upon examination. His HMO will not pay for a screening urinalysis.
Mr. Jones brings Ed back one month later, concerned about a report he received from the ER. Ed had fallen off the monkey bars and broke his arm. He was found to have blood in his urine (microscopic). Examination and renal ultrasonography in the ER were normal. Mr. Jones wants to know what the UA showed at the 6 year PE; you disclose to him that one was not done. PE - Chest, heart, abdomen, genitalia - all WNL. CVA non-tender. No edema, joints normal, no rash UA - clear yellow pH 6.5 S.G. 1.015 ++ Blood +15 (trace) alb - LE - Nitrite Micro - 10-15 RBC 0-3 WBC no casts tr Bacteria Several 'dysmorphic' RBC seen Urinary calcium/creatinine ratio 0.12 (<0.21) You ask father to get a urinalysis at his PCP's office, and ask Ed's brother to have a UA as well (he's not had a UA either). |
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