Case Study 44: Dark Urine in a Child - CRASH! Medical Review Series

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(Disclaimer: The medical information contained herein is intended for physician medical licensing exam review purposes only, and are not intended for diagnosis of any illness. If you think you may be suffering from any medical condition, you should consult your physician or seek immediate medical attention.)

[@woloabel]

(On Friday of March 24, 2023). On the Matter of Case Study 44 on a Clinical Presentation of Dark Urine in a Child (Pediatric Hematuria, Fatigue (Pallor), Anorexia and Hypertension) by MD Paul W. Bolin (CRASH! Medical Review Series): 1) Vitals: 1) BP 138/89 (Hypertension) and the Normal Vital Range for Pediatric Patient of 6-12 Years of Age is Systolic 80-120 and Diastolic 56-62 mmHg; 2) HR 83 BPM while the Pediatric Range is 70-110 BPM; 3) RR 23 while Normal is 20-30 RPM; 4) Temperature is 97.7 Degrees Fahrenheit while Normal Range is 97.9 Degrees to 100.4 Degrees Fahrenheit 5) Saturation is 100% on Room Air Ambient (RA; No indication of Hypoxia/Hypoxemia); 2) SSx of the Patient are 1) Hematuria (Dark Urine), 2) Fatigue (Constitutional Sign of Anemia [Most General Sign of On-going, Active Disease Process]) is Generally Feeling Tired and Lacking Vitality, 3) Anorexia (Lack of Appetite); 3) Past Medical History: 1) Pharyngitis the Week Past and Fever; 2) General Communicable Disease Process within the Entire Family (Viral Infection); 4) Medications are Negative; 5) DDx: 1) Membranoproliferative Glomerulonephritis (MPGN) is an Idiopathic and Also Status Post Infection Glomerulonephritis (Low C3 Serology however ASO and Anti-DNAse Negative; Renal Biopsy ultimately the Diagnostic Feature); 2) Acute Poststreptococcal Glomerulonephritis (APSGN); 3) IgA Nephropathy has a Similar Presentation (Mesangial Immunoglobulin A Complex Deposition) with Status Post an Upper Respiratory Infection (Five Days from an Infection [UTI,GI Infection, URI] and Hematuria, Proteinuria, Hypertension, Edema) with a Normal C3 Serology (Titers of Complement); 6) Physical Examination (Px): 1) General is revelatory of Malaise and Lack of Vitality with some Pallor (Less Normal Rubicon Complexion); 2) Skin has Normal Turgor and no Rashes (Lesions of Skin); 3) HEENT is Significant for 1) Periorbital Edema, 2) Conjunctival Pallor; 3) Otherwise Normal with Atraumatic Normocephalic, PERRLA, Clear Auditory Canal, Normal TM, Normal Oral/Pharyngeal Mucosa, Cervical LAN Negative (Absent Swelling within these Lymph Nodes) and A Supple Neck; 4) Chest/Lung is CTA; 5) CV is RRR and Absent Pathological Sounds (Murmurs And Gallops); 6) Abdomen is Soft, NT/ND, NBS, and Absent Organomegaly (Hepato/Spleno Enlargement Negative); 7) Extremities and Spine are Absent of Deformities, Peripheral Cyanosis Negative, Digital Clubbing, and Pitting Edema at the Ankles (Edema due to Renal Hypertension); 7) Diagnosis (Dx): 1) Initial Investigations of Prescreening Value: 1) CBC shows WBC at 7,300 per um; 2) Hemoglobin at 9.3 g/dL (Anemia; Low Parameter); 3) Hematocrit is 28.2 (Low; Anemia); 4) Platelets are 240,000 per um (Normal); 5) MCV at 88 fL; 2) Complete Metabolic Panel (CMP) is Significant for Low Albumin (Hypoalbuminemia); 3) Urinalysis shows Tea-Color Urine (Hematuria Positive), Proteinuria, Hematuria, RBC Casts and Dysmorphic Features in RBCs Localizing the Disease Process to the Glomerulus; 4) 24-Hour Urine Protein shows a Sub-Nephrotic Range Proteinuria Level. Nephritic Syndrome (Inflammation of the Glomerulus); 5) Antistreptolysin O (ASO) Titer (Blood Test checking for Antibodies to the Antigen of Beta-Hemolytic Bacteria are Present (Streptococcus Pyogenes Antibodies To Antigen Positive And/or Elevated); 6) Throat Culture are Typically Available Later (18-24 Hours of Incubation). Therefore, Pending Results; 7) Serum C3 and C4 (60 Protein System For Infection Clearing Purposes; C3 is a 187 kDa Glycoprotein [Hepatocyte/Keratinocyte Biosynthesis with 1663 Amino Acids]); C3 Level herein are Low and C4 Levels are Normal; 8) Renal Ultrasound is Unremarkable; 8) The Best Initial Assessment is Urinalysis; However, the most Accurate Diagnosis Methodology is Renal Biopsy, A Rare and Unnecessary in a Primary Care Physician Scenario; 9) Therefore, Acute Poststreptococcal Glomerulonephritis (APSGN); 8) Mangement of APSGN: 1) Advice Low-Sodium Diet; 2) Fluid Restriction (Not More than 2-Liters Per Day); 3) Furosemide (Diuretics Drug Class); 4) Anti-Hypertensives (Amlodipine CCB/Dihydropyridine Drug Class); 5) Reassure Patient and Parent; 6) Referral to Pediatric Nephrology/Urology; 9) Treatment (Tx): 1) Self-Limiting (However, Preventive Penicillin G is Advisable); 2) Acute Symptomatic Manifestation Treatment (Hypertension and Hypervolemia [Volume Overload]); 10) Pathology is a Hypersensitivity Type III Infiltration Disease Characterized by a Nephritic Inflammatory Process within the Glomerulus and is the Most Common Pediatric Aetiology of Glomerulonephritides. There is basically an Abnormal Immune Reaction to Antigen-Antibodies Complexes Reacting with Complement Protein Two (2) to three (3) Weeks Post Streptococcus Pyogenes Infection (Impetigo or Bacterial Pharyngitis). This Process understandably leads to Hypertension, Edema, Oliguria (RBC Casts, Abnormal Red Urine Color), Proteinuria (Although not Nephrotic Range), and other Symptoms. IgA Nephropathy is Easily Differentiated by the Normal C3 Complement Level and History (Family Outbreak or Recent Exposure and the Bacterial Pharyngitis Infection) Occuring Days not Weeks like PSGN or MPGN. 11) Complications (Cx): 1) Intracranial Hemorrhage (ICH) and Intracranial Edema (35%); 2) Acute Kidney Injury; 3) Chronic Kidney Disease; Goodness, my first Nephritic Diagnosis. Not Really, Just Kidding. The Patient Had Persistent Exposure to This Gram Positive Group A Streptococcus Pyogenes and Developed Rheumatic Fever (Scarlatina), Endocarditis along with Multiple Organ Dysfunction Syndrome (MODS). I had to Fix the Genetic Predisposition I describe as Superantigen Diathesis (Inheritance and Immunopathy; 6p22.1 Variation). MD Paul W. Bolin, es Geht sehr Gut zu verheilen und vernichten Weltkrankenheit aber man auch muess selbstheilung sein. Heil!

[@MohamedAli-bx9ut]

Gynecology and obstetrics cases???