1. By Brent Lee Lechner, DO MAJ, MC, USA
Blood in Urine By
Brent Lee Lechner, DO
MAJ, MC, USA

2. Outline Case Presentation Input on Labs and Rads Work-up
Audience
Work-up
Proteinuria Discussion
Trivia: Military Movies

3. Case Presentation 16 year old white male
Upper Respiratory Infection X 10 days
Pediatrician diagnosis: sinusitis
Amoxicillin Started
Rash after two days: Red, ? Hives
Changed antibiotics to Z-pack
Trip to Mexico
Two weeks later: periorbital edema and ankle swelling
Returns to Pediatrician with dark urine

4. Case Presentation No SOB, No trouble breathing No abdominal pain
No n/v/d, No f/u/d
Occasional headache: 1/ month
Relieved by Motrin
No blurred vision
No Joint pain, No arthritic pain

5. Case Presentation Past Medical History Past Surgical History
Exercise Induced Asthma
Past Surgical History
None
Medications
Albuterol MDI with Spacer
Motrin 400 mg for Pain
Allergies: NKDA
Amoxicillin: ? Rash
Imm: UTD
Family History
Father: Obese, HTN, Gout
Mother: None
Paternal GF: Bladder Cancer
Maternal GF: Death – MI
SSHx
Smoke: No!
ETOH: 1-2 times per month after football games
Drugs: No!
No Sexual activity
Middle Linebacker in Football
Goal: US Army Helicopter Pilot

6. Bonus Question
What “state” was the bar in which Maverick and Goose frequently sang “Great Balls of Fire” in Fighter Town, USA, named after?
Movie: TOP GUN

7. Questions as part of H&P
Fluid po intake?
4: 6 oz Glasses/ Day (usually iced tea with sugar)
Frequency of voids?
2-3 times per day
Weight Gain?
7 lbs
Recent colds or strep throat or impetigo?
No colds, URI, recent illness or rash

8. Other Questions as part of H&P
Flank pain or CVA tenderness?
None
Gross Hematuria?
Color: Sam Adams
Trauma?
Denies
Self-manipulation?
Yes, as all adolescents
Sexual history?
No, never been lucky

9. Other Questions as part of H&P
Circumsized or Hygiene ?
No but good hygiene and no signs of trauma
Medication History?
Motrin: 1 time per week
No Nutritional or steroid supplements
Family history of hematuria or hearing loss?
None: No ESRD, No Dialysis, No Renal Disease
Family history of stones?
Father: lithotrisomy

10. Physical Examination VSS T: 99. 1 BP: 143/89
Physical Examination VSS T: BP: 143/89 P:87 R:13 PO2:100% HGT: 5’8” WGT: 58 kg
Head: NC, 0 lesions
Eyes: PERRLA, EOMI, Normal Fundo B, B periorbital Edema 2+/4
Ears: B clear TM
Nose: Non-swollen turb.
Throat: non-red, 0 exudates
Neck: 0 LA, 0 mass, Supple
Genitalia: B Testes down, no trauma, no meatus tear
Chest: RRR,S1,S2, 0 m
Lungs: Decreased BS at bases
Abdomen: NT, Soft, BS(+), 0 HSM, Slightly Distended
Ext: 0 c/c, FROM, Cap Refill <2s, LE Edema 2+/4 at ankles
Pulses: 2+/2 all extremities
Back: Straight, 0 hair patch, 0 dimple

11. Bonus Question
In the movie “A scent of a woman,” how did the infantry colonel played by Al Pacino lose his sight?

12. Urine Tests Urinanalysis pH: 5.0 SG: 1.030 Ketones: (-) Glucose: (-)
Protein: 3+
Blood: Large
Nitrites: (-)
LE: (-)

16. Micro Exam of Urine Microscopy urine RBCs/hpf: 50+ WBCs/hpf: 0
Casts/hpf: 15+
Dysmorphic RBCs/hpf: 60%

17. Laboratory studies WBC: 7.1/mm3 X 1000 HBG: 13.2(g%) HCT: 37.5%
Platelets: 378 (103)/mm3
MCV: 73 fl

18. Laboratory Studies Na+: 129 mEq/L K+: 4.9 mEq/L Cl-: 108 mEq/L
HCO3-: mEq/L
BUN: mg/dl
Creatinine: 1.5 mg/dl
Ca 2+: mEq/L
PO4 2-: mg/dl
Mg 2+: mEq/L

19. Bonus Question
In the movie “An officer and gentleman,” what does Mayo’s (Richard Gere) friend (the guy from Oklahoma) tell his “girlfriend” (the girl faking the pregnancy) job is waiting at home?

20. Work-up of Hematuria
Must do urine microscopy after positive dipstick for blood
Urine Examination
RBCs: RBCs/hpf > 5 significant
Eumorphic versus Dysmorphic RBCs
Lower Tract versus Upper Tract
No RBCs: Think Pigmented Nephropathy
Myoglobinuria or Hemoglobulinuria
Usually Granular Casts!!

21. Evaluation of Dark Urine
Dipstick for Occult Blood
Negative Positive
Pigments No RBC RBC Present
Bilirubin Hemoglobin
Dyes Hemolysis
Drugs Myoglobin
Factitious Muscle Injury
Seizures Eumorphic Dysmorphic
(No RBC Casts) (RBC Casts)
T.I.C.S Nephritis
Acute
Chronic

22. Causes of Hematuria I C S T Tumor, TB,Trauma
Infection and Inflammation (Nephritis) C
Calcuria, Cystic Disease, congenital anomaly S
Sickle Cell Disease, Stones, Somewhere

23. Nephritis Differential Diagnosis
Nephritic Syndrome
Hypertension
Hematuria with active sediment
Azotemia

24. Nephritis Differential Diagnosis
Glomerulonephritis
Alport’s Syndrome
Membranoproliferative GN
Post Infectious GN
SLE
Hemolytic Uremic Syndrome
HSP

25. Bonus Question
What is the occupation and home state of Tom Hanks character in the movie “Saving Private Ryan,” prior to him entering the U.S. Army?

26. Laboratory Work-Up Urine culture Spot urine Ca++/creatinine ratio
If ratio > 0.2, then 24h urine Ca++ and creatinine
If 24 hour urine Ca++ greater than 4 mg/kg/d, then hypercalcuria
If protein on urine dipstick, then spot protein/creatinine urine ratio
If ratio > 0.2, then 24 hour protein in urine
Greater than 1000mg/day, significant proteinuria
Nephrotic Range (3.5 g/d or greater than 40 mg/kg/d )

27. Laboratory Work-up Blood tests: Chem 10 to check renal function
Serologies: C3, C4, ANA, Anti-Strep Dnase B, ASO
C3 and C4: low Stay low SLE
C3: low Stay low MPGN
C3: low Returns to normal (6-8 wks) PIGN
Consider HIV and Hepatitis B screen

28. Radiology Work-up Renal Ultrasound CT scan: gold standard for stones
Hydronephrosis in stones vs. anatomical process
Renal Mass (Wilm’s Tumor)
Cystic Disease
Unlikely but AVM
CT scan: gold standard for stones

29. Other tests Alport’s Syndrome: hearing and opthlmo exam
Rising creatinine, persistent low C3 or significant proteinuria, then consider biopsy.

30. Bonus Question
At the end of basic training in the movie “Full Metal Jacket,” what job in the U.S. Marine Corps does “Joker” obtain?

31. Our Patient
C3: 12 (90 – 120)
C4: 19 (12 – 26)
ANA (-)
ASO (-)
Anti-Dnase B (-)
Urine Ca/creatinine ratio: 0.06
Urine Protein /creatinine ratio: 3.2
24 hour urine
Protein: 3.6 g/d
Creatinine: 1.6 g/d
Repeat C3: 16 in 6 weeks with gradual increase in creatinine to 1.7 mg/dl

32. What does the Renal Biopsy Show?