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

2. Case Presentation
14 year old Mexican male, presents to the clinic after a recent
move from Brownville, TX with chief compliant of “blood in my urine.”
Before leaving Texas, the patient was seen in the pediatric clinic for a
routine physical. He states that the Texas doctor told him that he “had
blood in urine that was present under microscope.” He should his urine
rechecked after the move. The patient states that he “sometimes has pain
in his stomach” but it never stops him from football practice or going to
school. No frequency, urgency or dysuria. no gross hematuria, no
coca-cola or iced-tea colored urine. No nausea, vomiting and diarrhea; no
edema or swelling noted in ankle or eyelids, no odor to the urine.

3. 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
Imm: UTD
Family History
Father: NIDDIM, HTN
Mother: Obese, HTN
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

4. Physical Examination VSS T: 99. 1 BP: 103/64
Physical Examination VSS T: BP: 103/64 P:87 R:13 PO2:100% HGT: 5’6” WGT: 48 kg
Head: NC, 0 lesions
Eyes: PERRLA, EOMI, Normal Fundo B
Ears: B clear TM
Nose: Non-swollen turb.
Throat: non-red, 0 exudates
Neck: 0 LA, 0 mass, Supple
Chest: RRR,S1,S2, 0m
Lungs: B CTA without wheezing
Abdomen: ND/NT, Soft, BS(+), 0 HSM
Ext: 0 c/c/e, FROM, Cap Refill <2s
Pulses: 2+/2 all extremities
Back: Straight, 0 hair patch, 0 dimple

5. Other 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
Recent colds or strep throat or impetigo?
No colds, URI, recent illness or rash
Family history of hematuria or hearing loss?
None
Family history of stones?
Father: lithotrisomy
Flank pain or CVA tenderness?

6. Other Questions as part of H&P
Self-manipulation?
Yes, as all adolescents
Sexual history?
No, never been lucky
Circumsized or Hygiene ?
No but good hygiene and no signs of trauma
Medication History?
None

7. Urine Tests Urinanalysis pH: 5.0 SG: 1.030 Ketones: (-) Glucose: (-)
Protein: (1+)
Blood: Large
Nitrites: (-)
LE: (-)

8. Micro Exam of Urine Microscopy urine RBCs/hpf: 50+ WBCs/hpf: 0
Casts/hpf: 0
Dysmorphic RBCs/hpf: 0

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

10. Laboratory Studies Na+: 137 mEq/L K+: 4.6 mEq/L Cl-: 108 mEq/L
HCO3-: mEq/L
BUN: mg/dl
Creatinine: 0.7 mg/dl
Ca 2+: mEq/L
PO4 2-: mg/dl
Mg 2+: mEq/L

11. 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!!

12. 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

13. 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 40 mg/kg/d or 1000mg/day, significant proteinuria
Nephrotic Range (3.5 g/d)

14. 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

15. 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

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

17. 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

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

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