Case 21: Bloody urine

Opening scenario

Matthew Black, a 23-year-old male; , comes to the emergency department because of blood in his urine.

Vital signs

• Temperature: 98.6°F (37.0°C)
• Blood pressure: 135/85 mm Hg
• Heart rate: 80/min
• Respirations: 14/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• When the examinee gently thumps on the sides of your back around the bottom part of your rib cage, tell her/him that it hurts a little.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Will I need dialysis?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I have blood in my urine.
• Onset
• It started 2 days ago.
• Constant/intermittent
• My urine is really red every time I pee. It scares me.
• Precipitating events
• Hmmm...I am not sure. I had a cold 3 weeks ago. But I do not think that has anything to do with it.
• Progression
• It has been the same for the past 2 days.
• Previous episodes
• No, never.
• Alleviating factors
• Nothing.
• Aggravating factors
• Nothing.
• Associated symptoms
• I feel like I still have a little bit of a cough.
  • Onset
  • It started 3 weeks ago when I had that cold.
  • Progression
  • No.
  • Coughing up sputum
  • No.
  • Coughing up blood
  • No.

Review of systems specific to hematuria

• Headache
• No.
• Swelling of the ankles
• Now that you say it, my legs have been feeling a bit swollen for the past few days, yes. I even had trouble getting into my shoes this morning.
• Fever/chills
• Only when I had the cold 3 weeks ago.
• Night sweats
• No.
• Fatigue
• I have been feeling a little tired over the past 2 weeks.
• Rash/skin changes
• No.
• Chest pain
• No.
• Shortness of breath
• No.
• Pain in joints
• No.
• Urinary problems/changes in urinary frequency
• I think I have peed a little less the past week than I usually do.
• Weight changes
• I have not noticed any weight changes.
• Sore throat
• Right now I do not have a sore throat. 3 weeks ago when I had my cold my throat was really sore though.
• Back pain
• The sides of my back have been hurting for the past 3 days, yes.
• Runny nose
• Well, my nose always feels a little stuffed up.
• Earache
• No.
• Changes in vision
• No.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• None.
• Medications
• Just my daily saline nasal spray.
• Hospitalizations
• Never.
• Ill contacts
• None.
• Past surgical history
• None.
• Family history
• Everyone in my family is really healthy.
• Work
• I just finished my bachelor's degree, and now I am applying for law school.
• Home
• I just moved back in with my parents, but that is just until I get accepted to law school.
• Alcohol
• I'll have a beer or two on the weekends, but I don't usually drink during the week.
• Recreational drugs
• Never.
• Tobacco
• Yes. I have smoked about a pack a day for the past 5 years.
• Exercise
• I used to swim in college, and I usually still go swimming a few times a week. But for the last 3 weeks I have been too tired.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Palpation of the head
  • Inspection of the conjunctivae
  • Inspection of the ears
  • Palpation of the ears
  • Otoscopy
  • Inspection of the nose
  • Inspection of the oropharynx
• Neck examination
  • Palpation of the lymph nodes of the head and neck
• Back examination
  • Examination for costovertebral angle tenderness
    • Mild costovertebral tenderness bilaterally
• Cardiovascular examination
  • Auscultation of the heart
• Chest examination
  • Inspection of the chest
  • Palpation of the chest
  • Percussion of the lung fields
  • Auscultation of the lungs
  • Examination for fremitus
• Extremities
  • Examination for pitting edema
• Skin examination

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mr. Black, given the symptoms you are describing, I am concerned that your kidneys may be affected in some way. However, not every patient with kidney disease has to undergo dialysis, and, depending on the nature of the problem, the kidneys can often recover by themselves. I am glad that you came in today. I would like to run some tests to determine what exactly is going on, and then we can proceed from there. What do you think about that?”

Patient note

Differential diagnoses

1. Poststreptococcal glomerulonephritis: This patient has the telltale signs of nephritic syndrome: hematuria, elevated blood pressure, and lower extremity edema. He has other signs of kidney involvement as well, e.g., fatigue, subjectively decreased urine output, and flank pain. He had an upper respiratory infection 3 weeks ago, including a sore throat, which could very well have been tonsillopharyngitis caused by group A streptococci, the most common cause of poststreptococcal glomerulonephritis.
2. IgA nephropathy: IgA nephropathy is the main differential diagnosis for poststreptococcal glomerulonephritis. Patients present with symptoms similar to those of poststreptococcal glomerulonephritis, and peak incidence is in the second to third decades of life. IgA nephropathy usually occurs 2–5 days following an upper respiratory infection, which makes it a less likely cause in this patient, who has a history of infection 3 weeks prior to presentation.
3. Granulomatosis with polyangiitis (GPA): In addition to his obvious renal symptoms, this patient has some symptoms that should raise concern for pulmonary involvement (e.g., chronic rhinitis and persistent cough). Pulmonary-renal syndromes can be caused by vasculitides, such as GPA, which involves chronic rhinitis and other ear, nose, and throat complaints in ∼ 90% of cases. However, given this patient's history of sore throat and upper respiratory infection, the peak incidence of GPA at 65–74 years of age, and the relative rarity of GPA, the other two diagnoses should be considered first.

Hematuria shortly after an upper respiratory tract infection can indicate poststreptococcal glomerulonephritis or IgA nephropathy.

If the doorway information includes hematuria and elevated blood pressure, always include glomerulonephritis in your differential diagnoses.

Diagnostic studies

• Ultrasound of the kidneys: may show enlarged kidneys in poststreptococcal glomerulonephritis
• Urinalysis with urine microscopy: Nephritic sediment is a classic finding in poststreptococcal glomerulonephritis, IgA nephropathy, and GPA.
• CBC, ESR: CBC may show anemia in GPA and poststreptococcal glomerulonephritis. A significantly elevated ESR is typical for GPA.
• BUN, creatinine: Kidney function should be assessed in all cases of suspected kidney disease.
• Antistreptolysin titer, complement levels: Poststreptococcal glomerulonephritis after an infection of the throat typically results in an elevated antistreptolysin titer and decreased C3 complement, which is normal in IgA nephropathy.
• c-ANCA: positive in almost 90% of patients with GPA
• CXR: Chest x-ray/CT may show multiple bilateral cavitating nodular lesions in GPA.
• Renal biopsy: In poststreptococcal glomerulonephritis and IgA nephropathy , patient history and laboratory evaluation usually suffice for diagnosis. However, renal biopsy is the only diagnostic test capable of truly confirming these diagnoses, and it is therefore used in ambiguous cases or severe or progressive disease. Diagnosis of GPA should be confirmed via biopsy of affected tissue, e.g., of the kidneys.

Other differentials to consider

• See also “Etiology” of nephritic syndrome.
• Pyelonephritis
• Urolithiasis
• Tuberculosis