Q 1- 3:
A 4-year-old boy presented with a week’s history of diarrhoea and vomiting, followed 2 days later with pyrexia and lethargy. On presentation he was unable to tolerate any oral intake and had reduced urinary output. His parents had noticed abdominal and ankle swelling.
Blood tests showed:
Na - 129 mmol/litres
K -4 mmol/litres
Urea - 3.7 mmol/litres
Creat - 16 umol/litres
Albumin - 13 g/litres
Urine dip showed:
Protein : +++
Blood : -
( Q 1) What is the most likely diagnosis?
A- Nephrotic syndrome
B- Viral gastroenteritis
C- Haemolytic uraemic syndrome
D- Hyponatraemic dehydration
E- Urinary tract infection
( Q 2) How would you treat him?
A- Phenoxymethylpenicillin
B- Salt and fluid restriction
C- Oral prednisolone
D- Pneumococcal vaccination
E- All of the above
Despite 1 month’s treatment with high-dose oral steroids and fluid restriction of 750 ml/24 hours, he had continued proteinuria and oedema. He was then admitted for a 3-day course of intravenous corticosteroids, methyl-prednisolone, without resolution of the proteinuria.
( Q 3 ) The next best course of action is
A- Human albumin solution infusion
B- Renal biopsy
C- Increased dose of intravenous steroids for further 1 week
D- Greater fluid restriction to 500 ml/24 hours
Answers
Q1: A
Q2 : E
Q 3: B
Nephrotic syndrome, NS, is diagnosed with the triad of oedema, proteinuria (>1 g/m2/24 hours), and hypoalbunaemia (<25 g/litres). Oedema is most easily noted in peripheries, genitals and periorbital areas. Abdominal ascites can also occur, and when present, there is a risk of spontaneous bacterial peritonitis.
Oral penicillin V, is therefore recommended as prophylaxis.
Complement and immunoglobulins are proteins and are also lost, thus reducing immunity and increasing susceptibility to infection. Booster immunizations may be required, especially pneumococcal vaccination.
NS can be classified into primary, secondary or congenital.
Primary NS, is idiopathic, and related to glomerular diseases; it can be further stratified into minimal change
(80e90%) or focal segmental glomerulosclerosis (10e20%). Secondary NS is caused by systemic illnesses
such as HenocheSchonlein purpura or systemic lupus erythematosus.
Children without evidence of systemic illness, and who appear to have isolated NS, without evidence of hypertension or macroscopic haematuria can be started empirically
on steroid treatment.
Those who are unresponsive to steroid treatment, or who exhibit atypical features, should be considered for
renal biopsy.
For those children unresponsive to steroid treatment, further treatment is available with levamisole, cyclophosphamide, cyclosporine, or mycophenylate Mofitil.
------------
Q4:
A 5-year-old boy presents with dark red urine, fever, and rhinorrhea. He was well until 2 days
ago, when he developed rhinorrhea and mild cough. He denies urgency, frequency, dysuria,
back pain, or musculoskeletal complaints. On physical examination, the slightly ill-appearing boy
has a temperature of 99.5°F (37.5°C), heart rate of 130 beats/min, respiratory rate of 18
breaths/min, and blood pressure of 104/58 mm Hg. He has pale conjunctivae, mild scleral
icterus, a hyperdynamic precordium, and a I/VI systolic murmur at the left upper sternal border.
There is no edema, and musculoskeletal and neurologic examination results are normal.
Urinalysis results include: red appearance, a specific gravity of 1.030, pH of 6.5, 3+ blood, and
no protein. Microscopy reveals fewer than 5 red blood cells/high-power field (HPF), fewer than 5
white blood cells/HPF, and no casts.
Of the following, the BEST initial test to obtain is
A. complete blood count with manual differential count
B. creatine phosphokinase measurement
C. renal/bladder ultrasonography
D. urine culture
E. viral culture of urine for adenovirus
Answer:
A
The differential diagnosis for causes of red urine includes hematuria, hemoglobinuria, myoglobinuria, and porphyrinuria.
Some urinary tract pathogens (eg. Serratia marcescens) also can be associated with red urine. In addition, red urine can result from ingestion of certain foods (beets, blackberries, or food dyes) and medications (deferoxamine, rifampin, and phenolphthalein).
The initial test for evaluating a child who has red urine is the urinalysis to look for the presence or absence of blood. The 3+ blood on a dipstick described for the child in the vignette narrows the differential diagnosis to hematuria, hemoglobinuria, or myoglobinuria.
The dipstick test incorporates an indicator impregnated into the paper strip that, upon contact with free
hemoglobin, myoglobin, or intact red blood cells, oxidizes the indicator to result in a blue color change. This dipstick test is exquisitely sensitive to blood to the level of 5 red blood cells/highpower field. The fewer than 5 red blood cells/high power field on microscopy described for the patient in the vignette eliminates hematuria.
The presence of tachycardia, pale conjunctivae, and a systolic murmur is suggestive of anemia, and scleral icterus supports a possible hemolytic anemia. Accordingly, a complete blood count to assess for anemia is the most appropriate next laboratory test to obtain for this boy.
The absence of musculoskeletal complaints and normal musculoskeletal and neurologic examination results make myoglobinuria (usually related to rhabdomyolyis) unlikely. If myoglobinuria was suspected, measurement of creatine phosphokinase would be useful.
Renal/bladder ultrasonography is helpful in evaluating patients who have bright red urine,with clots and red blood cells noted on urinalysis. Such findings are suggestive of a structural cause for the red urine, such as renal or bladder mass or stones.
Red urine caused by bacterial or viral infections is due to hematuria. Thus, culture of the urine for bacteria or viral culture for adenovirus is inappropriate because this boy does not have hematuria.
----
Q5 - 6:
Q 5:
A 5-year-old boy has a history of bed-wetting about four to five times a week. He has recently begun to attend kindergarten. He was toilet trained (dry during the day) by age 3 but has never been consistently dry at night. He denies any dysuria or frequency. There is no history of increased thirst or frequent urination. The urinalysis is negative for blood, protein, glucose, or ketones; there are no white cells or bacteria; the specific gravity is 1.020. Which of the following is the most likely diagnosis?
(A) a urinary tract infection (UTI)
(B) primary nocturnal enuresis
(C) secondary enuresis caused by stress of the new school
(D) diabetes mellitus
(E) diabetes insipidus
Q 6:
The parents request some treatment for thiscondition. Which of the following is the most appropriate treatment for a child of this age?
(A) bladder stretching exercises
(B) intranasal DDAVP (desmopressin acetate)
(C) imipramine
(D) conditioning therapy with a bed-wetting alarm
(E) reassurance of the parents and restriction of fluids before bedtime
Answers :
Q 5:
(B)
Enuresis may be primary (75%) where nocturnal control was never achieved; secondary enuresis (25%) is when the child was dry at night for at least a few months.
Nocturnal enuresis is more common in boys, and family history is positive in at least 50%. This may affect as much as 20% of children at age 5 years, and it spontaneously stops in at least 15% of affected children every year. Psychological factors are often involved in secondary enuresis.
A careful history should be obtained to rule out such organic factors as UTI (dysuria, frequency, urgency). Children with diabetes insipidus or diabetes mellitus have polydipsia and polyuria.
Urinalysis should be considered to rule out an organic cause. In diabetes mellitus, urinalysis may reveal glycosuria and ketonuria. Aurinespecific gravity of >1.015 makes diabetes insipidus unlikely.
Q 6:
(E)
Active treatment should be avoided in children under age 6 years, as nocturnal enuresis is common. Parents should be reassured that the condition is self-limited. Fluid intake 1 hour before sleep should be restricted. Simple behavioral reinforcement, such as a star or sticker chart to record dry nights, may be helpful. Punitive or humiliating measures should be discouraged.
Bladder-stretching exercises and encouraging children to hold urine for longer periods during the day are usually not helpful. Pharmacologic therapy is not curative. DDAVP is a synthetic analog of antidiuretic hormone. It reduces urine production overnight. Hyponatremia has been reported with use of this drug. If used, it should only be for a limited time. Imipramine is a tricyclic antidepressant which was used more often
in the past. It is effective in 30–60% of children, but side effects include anxiety, insomnia, and dry mouth.
There is a poisoning risk, especially for younger children. Conditioning therapy may be considered in children older than 6 years. Success rates range from 30 to 60%. It involves the use of an alarm attached to electrodes in the underwear, which sounds when the child voids.
Consistent use of the device is often helpful; it is more effective in older, more motivated children. A common complaint is that the alarm wakes up other family members but not the affected child.
---------------
Q 7:
An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also
vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no
apparent source of infection. She appeared to be 5–10% dehydrated.
You decide to obtain a urine specimen for analysis and culture. Which of the following is the best method?
(A) Collect a midstream “clean catch” specimen.
(B) Collect a catheterized specimen.
(C) Place an adhesive bag to collect urine.
(D) Obtain urine from a diaper.
(E) Collect urine after she urinates in a potty chair
Q8:
Her urinalysis shows a urine specific gravity of 1.030, trace blood, and protein. Nitrite and
leukocyte esterase are both positive. Microscopic examination of unspun urine shows >100 white
blood cells (WBCs) and 0–5 red blood cells (RBCs) per high-power field, as well as many bacteria. Aurine culture is sent. Which of the following is the most appropriate management plan?
(A) Treat only if the culture is positive.
(B) Admit for intravenous (IV) hydration and IV antibiotics.
(C) Treat with intramuscular ceftriaxone and have her follow-up in the office the following day.
(D) Treat with trimethoprimsulfamethoxazole, and have her followup
in the office the following day.
(E) Prescribe amoxicillin and start oral hydration.
Q 9:
Her urine culture is positive at 24 hours. Which of the following is the most likely organism?
(A) Klebsiella
(B) Escherichia coli
(C) Staphylococcus saprophyticus
(D) Proteus
(E) Enterococcus
Q 10:
After the infection has been treated, which one of the following tests should be considered?
(A) no tests are needed
(B) renal ultrasound
(C) voiding cystourethrogram (VCUG)
(D) renal ultrasound and a VCUG
(E) radionucleotide renal scan
All
B
Urine for urinalysis and culture must be properly obtained. Catheterization is the most reliable method of the choices offered. Suprapubic tap is considered the “gold-standard” but is not always technically feasible, especially in an outpatient office setting.
Amidstream, clean catch specimen would be acceptable in an older, toilet-trained child. “Bagged” specimens are not recommended because of possible skin or fecal contamination of the specimen. Similarly,
obtaining a sample from a diaper or potty would be unacceptable. Urinalysis includes dipstick
method and microscopic examination.
Leukocyte esterase (an enzyme in WBC) and nitrites suggest probable infection. Microscopic analysis of unspun urine for WBC (>10/highpower field) or bacteria is also predictive of infection. RBCs are often present in a UTI.
The patient is vomiting and dehydrated;this may indicate possible pyelonephritis. The most appropriate course would be IV hydration and empiric treatment with antibiotics (ceftriaxone) while awaiting cultures. Children with pyelonephritis are at increased risk of renal scarring, especially younger children, and should be
treated early. E. coli is the most common organism cultured; others include Proteus, Klebsiella, S. saprophyticus, and Enterococcus. The occurrence of a UTI in a girl under age 3–5 years and in a
boy of any age may be a marker for an underlying congenital anatomic abnormality, in particular,
vesicourethral reflux. Radiologic investigation with renal ultrasound and VCUG is recommended.
Answers
Q1: A
Q2 : E
Q 3: B
Nephrotic syndrome, NS, is diagnosed with the triad of oedema, proteinuria (>1 g/m2/24 hours), and hypoalbunaemia (<25 g/litres). Oedema is most easily noted in peripheries, genitals and periorbital areas. Abdominal ascites can also occur, and when present, there is a risk of spontaneous bacterial peritonitis.
Oral penicillin V, is therefore recommended as prophylaxis.
Complement and immunoglobulins are proteins and are also lost, thus reducing immunity and increasing susceptibility to infection. Booster immunizations may be required, especially pneumococcal vaccination.
NS can be classified into primary, secondary or congenital.
Primary NS, is idiopathic, and related to glomerular diseases; it can be further stratified into minimal change
(80e90%) or focal segmental glomerulosclerosis (10e20%). Secondary NS is caused by systemic illnesses
such as HenocheSchonlein purpura or systemic lupus erythematosus.
Children without evidence of systemic illness, and who appear to have isolated NS, without evidence of hypertension or macroscopic haematuria can be started empirically
on steroid treatment.
Those who are unresponsive to steroid treatment, or who exhibit atypical features, should be considered for
renal biopsy.
For those children unresponsive to steroid treatment, further treatment is available with levamisole, cyclophosphamide, cyclosporine, or mycophenylate Mofitil.
------------
Q4:
A 5-year-old boy presents with dark red urine, fever, and rhinorrhea. He was well until 2 days
ago, when he developed rhinorrhea and mild cough. He denies urgency, frequency, dysuria,
back pain, or musculoskeletal complaints. On physical examination, the slightly ill-appearing boy
has a temperature of 99.5°F (37.5°C), heart rate of 130 beats/min, respiratory rate of 18
breaths/min, and blood pressure of 104/58 mm Hg. He has pale conjunctivae, mild scleral
icterus, a hyperdynamic precordium, and a I/VI systolic murmur at the left upper sternal border.
There is no edema, and musculoskeletal and neurologic examination results are normal.
Urinalysis results include: red appearance, a specific gravity of 1.030, pH of 6.5, 3+ blood, and
no protein. Microscopy reveals fewer than 5 red blood cells/high-power field (HPF), fewer than 5
white blood cells/HPF, and no casts.
Of the following, the BEST initial test to obtain is
A. complete blood count with manual differential count
B. creatine phosphokinase measurement
C. renal/bladder ultrasonography
D. urine culture
E. viral culture of urine for adenovirus
Answer:
A
The differential diagnosis for causes of red urine includes hematuria, hemoglobinuria, myoglobinuria, and porphyrinuria.
Some urinary tract pathogens (eg. Serratia marcescens) also can be associated with red urine. In addition, red urine can result from ingestion of certain foods (beets, blackberries, or food dyes) and medications (deferoxamine, rifampin, and phenolphthalein).
The initial test for evaluating a child who has red urine is the urinalysis to look for the presence or absence of blood. The 3+ blood on a dipstick described for the child in the vignette narrows the differential diagnosis to hematuria, hemoglobinuria, or myoglobinuria.
The dipstick test incorporates an indicator impregnated into the paper strip that, upon contact with free
hemoglobin, myoglobin, or intact red blood cells, oxidizes the indicator to result in a blue color change. This dipstick test is exquisitely sensitive to blood to the level of 5 red blood cells/highpower field. The fewer than 5 red blood cells/high power field on microscopy described for the patient in the vignette eliminates hematuria.
The presence of tachycardia, pale conjunctivae, and a systolic murmur is suggestive of anemia, and scleral icterus supports a possible hemolytic anemia. Accordingly, a complete blood count to assess for anemia is the most appropriate next laboratory test to obtain for this boy.
The absence of musculoskeletal complaints and normal musculoskeletal and neurologic examination results make myoglobinuria (usually related to rhabdomyolyis) unlikely. If myoglobinuria was suspected, measurement of creatine phosphokinase would be useful.
Renal/bladder ultrasonography is helpful in evaluating patients who have bright red urine,with clots and red blood cells noted on urinalysis. Such findings are suggestive of a structural cause for the red urine, such as renal or bladder mass or stones.
Red urine caused by bacterial or viral infections is due to hematuria. Thus, culture of the urine for bacteria or viral culture for adenovirus is inappropriate because this boy does not have hematuria.
----
Q5 - 6:
Q 5:
A 5-year-old boy has a history of bed-wetting about four to five times a week. He has recently begun to attend kindergarten. He was toilet trained (dry during the day) by age 3 but has never been consistently dry at night. He denies any dysuria or frequency. There is no history of increased thirst or frequent urination. The urinalysis is negative for blood, protein, glucose, or ketones; there are no white cells or bacteria; the specific gravity is 1.020. Which of the following is the most likely diagnosis?
(A) a urinary tract infection (UTI)
(B) primary nocturnal enuresis
(C) secondary enuresis caused by stress of the new school
(D) diabetes mellitus
(E) diabetes insipidus
Q 6:
The parents request some treatment for thiscondition. Which of the following is the most appropriate treatment for a child of this age?
(A) bladder stretching exercises
(B) intranasal DDAVP (desmopressin acetate)
(C) imipramine
(D) conditioning therapy with a bed-wetting alarm
(E) reassurance of the parents and restriction of fluids before bedtime
Answers :
Q 5:
(B)
Enuresis may be primary (75%) where nocturnal control was never achieved; secondary enuresis (25%) is when the child was dry at night for at least a few months.
Nocturnal enuresis is more common in boys, and family history is positive in at least 50%. This may affect as much as 20% of children at age 5 years, and it spontaneously stops in at least 15% of affected children every year. Psychological factors are often involved in secondary enuresis.
A careful history should be obtained to rule out such organic factors as UTI (dysuria, frequency, urgency). Children with diabetes insipidus or diabetes mellitus have polydipsia and polyuria.
Urinalysis should be considered to rule out an organic cause. In diabetes mellitus, urinalysis may reveal glycosuria and ketonuria. Aurinespecific gravity of >1.015 makes diabetes insipidus unlikely.
Q 6:
(E)
Active treatment should be avoided in children under age 6 years, as nocturnal enuresis is common. Parents should be reassured that the condition is self-limited. Fluid intake 1 hour before sleep should be restricted. Simple behavioral reinforcement, such as a star or sticker chart to record dry nights, may be helpful. Punitive or humiliating measures should be discouraged.
Bladder-stretching exercises and encouraging children to hold urine for longer periods during the day are usually not helpful. Pharmacologic therapy is not curative. DDAVP is a synthetic analog of antidiuretic hormone. It reduces urine production overnight. Hyponatremia has been reported with use of this drug. If used, it should only be for a limited time. Imipramine is a tricyclic antidepressant which was used more often
in the past. It is effective in 30–60% of children, but side effects include anxiety, insomnia, and dry mouth.
There is a poisoning risk, especially for younger children. Conditioning therapy may be considered in children older than 6 years. Success rates range from 30 to 60%. It involves the use of an alarm attached to electrodes in the underwear, which sounds when the child voids.
Consistent use of the device is often helpful; it is more effective in older, more motivated children. A common complaint is that the alarm wakes up other family members but not the affected child.
---------------
Q 7:
An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also
vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no
apparent source of infection. She appeared to be 5–10% dehydrated.
You decide to obtain a urine specimen for analysis and culture. Which of the following is the best method?
(A) Collect a midstream “clean catch” specimen.
(B) Collect a catheterized specimen.
(C) Place an adhesive bag to collect urine.
(D) Obtain urine from a diaper.
(E) Collect urine after she urinates in a potty chair
Q8:
Her urinalysis shows a urine specific gravity of 1.030, trace blood, and protein. Nitrite and
leukocyte esterase are both positive. Microscopic examination of unspun urine shows >100 white
blood cells (WBCs) and 0–5 red blood cells (RBCs) per high-power field, as well as many bacteria. Aurine culture is sent. Which of the following is the most appropriate management plan?
(A) Treat only if the culture is positive.
(B) Admit for intravenous (IV) hydration and IV antibiotics.
(C) Treat with intramuscular ceftriaxone and have her follow-up in the office the following day.
(D) Treat with trimethoprimsulfamethoxazole, and have her followup
in the office the following day.
(E) Prescribe amoxicillin and start oral hydration.
Q 9:
Her urine culture is positive at 24 hours. Which of the following is the most likely organism?
(A) Klebsiella
(B) Escherichia coli
(C) Staphylococcus saprophyticus
(D) Proteus
(E) Enterococcus
Q 10:
After the infection has been treated, which one of the following tests should be considered?
(A) no tests are needed
(B) renal ultrasound
(C) voiding cystourethrogram (VCUG)
(D) renal ultrasound and a VCUG
(E) radionucleotide renal scan
All
B
Urine for urinalysis and culture must be properly obtained. Catheterization is the most reliable method of the choices offered. Suprapubic tap is considered the “gold-standard” but is not always technically feasible, especially in an outpatient office setting.
Amidstream, clean catch specimen would be acceptable in an older, toilet-trained child. “Bagged” specimens are not recommended because of possible skin or fecal contamination of the specimen. Similarly,
obtaining a sample from a diaper or potty would be unacceptable. Urinalysis includes dipstick
method and microscopic examination.
Leukocyte esterase (an enzyme in WBC) and nitrites suggest probable infection. Microscopic analysis of unspun urine for WBC (>10/highpower field) or bacteria is also predictive of infection. RBCs are often present in a UTI.
The patient is vomiting and dehydrated;this may indicate possible pyelonephritis. The most appropriate course would be IV hydration and empiric treatment with antibiotics (ceftriaxone) while awaiting cultures. Children with pyelonephritis are at increased risk of renal scarring, especially younger children, and should be
treated early. E. coli is the most common organism cultured; others include Proteus, Klebsiella, S. saprophyticus, and Enterococcus. The occurrence of a UTI in a girl under age 3–5 years and in a
boy of any age may be a marker for an underlying congenital anatomic abnormality, in particular,
vesicourethral reflux. Radiologic investigation with renal ultrasound and VCUG is recommended.
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