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Urinalysis CPC Session: Cases for Interpretation Instructor version

Urinalysis CPC Session: Cases for Interpretation Instructor version. Urinalysis CPC: Case 1. Macroscopic analysis.

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Urinalysis CPC Session: Cases for Interpretation Instructor version

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  1. Urinalysis CPC Session: Cases for InterpretationInstructor version

  2. Urinalysis CPC: Case 1 Macroscopic analysis Clinical: A 34-year-old woman presents to the clinic with a complaint of chronic fatigue that has been increasing in severity over the past 4 weeks. She has no other specific complaints. A urinalysis is performed with the following results: Chemical analysis Microscopic analysis

  3. Urinalysis CPC: Case 1 Clinical: A 34-year-old woman presents to the clinic with a complaint of chronic fatigue that has been increasing in severity over the past 4 weeks. Urination is normal. A urinalysis is performed with the following results: Interpretation: This patient has glucosuria with mild ketonuria and more acidic urine. Hyaline casts are also present. Summary: In this patient, consider diabetes mellitus, given the clinical history and UA findings.

  4. Urinalysis CPC: Case 2 Clinical: A 55-year-old man presents with burning on urination for 3 days, malaise and fatigue. He has had increased fluid intake and voiding. He is not on diuretics or other medications. A urinalysis is performed with the following results:

  5. Urinalysis CPC: Case 2 Clinical: A 55-year-old man presents with burning on urination for 3 days, malaise and fatigue. He has had increased fluid intake and voiding. He is not on diuretics or other medications. A urinalysis is performed with the following results: Interpretation: This pattern favors infection. The dilute urine fits with his history, so RBCs or WBCs may be underestimated on microscopic (lysed). RBCs likely present due to irritation of GU tract. No WBC casts, so involvement of kidney by infection is less likely. Summary: Urinary tract infection, probably lower tract.

  6. Urinalysis CPC: Case 3 Clinical: An 8-year-old girl presents with edema that has been present for 2 weeks. A urinalysis is performed with the following results:

  7. Urinalysis CPC: Case 3 Clinical: An 8-year-old girl presents with edema that has been present for 2 weeks. A urinalysis is performed with the following results: Interpretation: This patient has significant proteinuria with fatty casts. As you will learn later in the block, you might suspect nephrotic syndrome in this patient. Young children don’t normally have significant proteinuria. This may indicate a glomerular problem. Summary: Significant proteinuria with fatty casts. Consider quantification of the amount of proteinuria with a 24-hour urine collection.

  8. Urinalysis CPC: Case 4 Clinical: A 12-year- old boy develops a petechial rash over his legs which has persisted for a month. He also has hypertension and an elevated serum creatinine. A urinalysis is performed with the following results:

  9. Urinalysis CPC: Case 4 Clinical: A 12-year-old boy develops a petechial rash over his legs which has persisted for a month. He also has hypertension and an elevated serum creatinine. A urinalysis is performed with the following results: Interpretation: This patient has proteinuria and hematuria. The microscopic fits with the dipstick findings. The presence of RBC casts is significant. Summary: In this patient with hematuria, proteinuria, and RBC casts, consider renal injury. More specifically, consider glomerular bleeding/injury (nephritic syndrome).

  10. Urinalysis CPC: Case 5 Clinical: A 30-year-old man is brought to the emergency department following a motorcycle accident. A urinalysis is performed with the following results:

  11. Urinalysis CPC: Case 5 Interpretation: Urine is red, which fits with 3+ blood. But, we would expect more RBCs on microscopic. Did RBCs lyse because of dilute urine? No…urine is concentrated…So, consider presence of myoglobin (or hemoglobin), which could turn dipstick positive and account for discrepancy between dipstick blood and microscopic evaluation. Tubular epithelial cells may indicate tubular damage, caused by myoglobin’s toxic effect on tubule epithelium. Protein + may also be due to presence of myoglobin in urine. Clinical: A 30-year-old man is brought to the emergency department following a motorcycle accident. A urinalysis is performed with the following results: Summary: Likely hematuria PLUS myoglobinuria due to muscle injury from trauma.

  12. Urinalysis CPC: Case 6 Clinical: A 58-year-old man with severe uncontrolled hypertension presents for evaluation. He is non-compliant with his medications and rarely keeps his scheduled appointments. A urinalysis is performed with the following results:

  13. Urinalysis CPC: Case 6 Clinical: A 58-year-old man with severe uncontrolled hypertension presents for evaluation. He is non-compliant with his medications and rarely keeps his scheduled appointments. A urinalysis is performed with the following results: Interpretation: This patient has proteinuria and waxy casts, without much else. In a patient with longstanding severe hypertension, this may mean he has chronic kidney disease/chronic renal failure. Summary: Consider chronic renal failure with proteinuria. May want to get a serum creatinine. NOTE: If s.g. is “fixed” on multiple occasions at 1.010, this may also indicate significant renal (tubular) damage.

  14. Urinalysis CPC: Case 7 Clinical: A 24-year-old soldier has recently returned from service in Africa. He was not stationed in a country where Ebola virus is prominent. He recently developed a severe chill and fever. A urinalysis is performed with the following results:

  15. Urinalysis CPC: Case 7 Clinical: A 24-year-old soldier has recently returned from service in Africa. He was not stationed in a country where Ebola virus is prominent. He recently developed a severe chill and fever. A urinalysis is performed with the following results: Interpretation: Dark brown color fits with dipstick blood 3+, but microscopic doesn’t correlate. RBCs probably didn’t lyse because urine isn’t dilute. So, consider presence of hemoglobin or myoglobin that turns dipstick positive (fits with hemoglobin casts). Increased urobilinogen suggests increased bilirubin excretion into GI tract. Summary: Clinical history & UA results suggest acute hemolysis. Consider malaria, given recent travel history.

  16. Urinalysis CPC: Case 8 Clinical: A 50-year-old man who is undergoing chemotherapy for lung cancer develops intense right-sided flank pain radiating down to his right groin. He has a history of diabetes mellitus and hypertension. A urinalysis is performed with the following results:

  17. Urinalysis CPC: Case 8 Clinical: A 50-year-old man who is undergoing chemotherapy for lung cancer develops intense right-sided flank pain radiating down to his right groin. He has a history of diabetes mellitus and hypertension. A urinalysis is performed with the following results: Interpretation: The clinical history suggests stone passage. Pink color could indicate the presence of blood…Certain crystals/stones tend to form in acidic urine. Blood and WBCs could be due to stone/crystal trauma and inflammation. Needle-like crystals could be uric acid. Summary: Clinical history and UA findings consistent with passage of uric acid stone. Chemotherapy can cause rapid lysis of tumor cells, which results in excess uric acid in system. This can lead to uric acid stone formation. Now, efforts are taken to reduce the incidence of uric acid stone formation in this setting.

  18. Urinalysis CPC: Case 9 Clinical: A 27-year-old prisoner complains of fever, recent weight loss, back pain, nausea, vomiting, malaise and fatigue. He has a history of substance abuse and was recently incarcerated for burglary. A urinalysis is performed with the following results:

  19. Urinalysis CPC: Case 9 Clinical: A 27-year-old prisoner complains of fever, recent weight loss, back pain, nausea, vomiting, malaise and fatigue. He has a history of substance abuse and was recently incarcerated for burglary. A urinalysis is performed with the following results: Interpretation: Green color and bilirubin fit together, so he possibly has a liver problem. It’s not bile duct obstruction, because urobilinogen is positive. Alkaline urine with nitrite, LE and WBCs and WBC casts point to kidney infection. RBCs probably present due to irritation & infection. Summary: Consider liver disease, renal infection, STIs.

  20. Urinalysis Patterns to Recognize • “Normal” • Non-specific “stress” changes (UA Case 1 from Case Study lecture) • Dehydration with/without ketosis (UA Case 2 from Case Study lecture) • Biliary tract obstruction (UA Case 3 from Case Study lecture) • Pyelonephritis – Upper Urinary Tract Infection (UA Case 4 from Case Study lecture)

  21. More Urinalysis Patterns to Recognize • Diabetes mellitus (CPC Case 1) • Lower urinary tract infection (CPC Case 2) • Heavy proteinuria (CPC Case 3) • Glomerular bleeding/injury (CPC Case 4) • Hematuria/Myoglobinuria (CPC Case 5) • Chronic renal disease (CPC Case 6) • Hemolysis (CPC Case 7) • Stone passage (CPC Case 8, also tumor lysis) • Liver disease (CPC Case 9, other things included)

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