CASE STUDY DISCUSSION

Case 1.

A 28 year old man visits his physician complaining of an intense, sharp pain in his back and side.  In a conversation with his physician, the patient confesses to eating a diet high in animal proteins such as meat, cheese, and fish.  Results of a complete urinalysis are shown below.

Chemical/Physical AnalysisColor Yellow Glucose Negative Urobilinogen NormalAppearance Clear Protein Trace Blood LargeSpecific Gravity 1.025 Ketones 150mg/dL Nitrite NegativepH 5.0 Bilirubin Negative Leukocyte NegativeMicroscopic Analysis >100 RBC/hpf 0-3 WBC/hpf 20-30 Bacteria/hpf 0-5 Squamous Epithelial Cells/hpf Unidentified Crystals  Questions 1.    Is there a discrepancy between the leukocyte and nitrite counts on the reagent stix compared to the results reported in the microscopic analysis? 2.    Is the presence of WBCs with bacteria clinically significant?3.    Suggest an explanation for blood in the urine. 

Case 2.

A 10 year old boy, who recently recovered from a streptococcal infection, was taken to the doctor with symptoms including fever, nausea, and malaise.  Physical examination reveals edema around the eyes and the knees.  Blood tests reveal a decrease in serum complement.  A routine urinalysis reveals the following results.

Chemical/Physical Analysis

Color Yellow Blood ModerateClarity Hazy pH 6.5Glucose Negative Protein 300mg/dLBilirubin Negative Urobilinogen NormalKetones Negative Leukocyte Esterase SmallSpecific Gravity 1.015 Nitrite Negative

Microscopic Analysis 20-50 RBC/hpf 10-20 WBC/hpf 2-5 RBC casts/lpf 2-5 Granular casts/lpf

Questions

1.    What is the significance of a positive leukocyte esterase?  2.    How could there be a positive leukocyte esterase and a negative nitrite?  3.    What is the significance of the presence of blood along with protein in the urine?4.    What disease are the results indicative of? 

Case 3.

A 10-year old girl had a routine urine exam at the time of her school physical. Results follow:

Questions

1. Identify the abnormal test results highlighted2. What is the most probable diagnosis for this patient? Support your answer (include in your discussion the physical, chemical and microscopic findings).3. Based on your diagnosis, what follow up testing should be done on this urine?4. What single microscopic finding is most helpful in differentiating an upper UTI from a lower UTI?

Case 4.

A 14-year-old boy is brought to the pediatrician by his mother because he has had a fever with shaking chills for the past day. On physical examination, he has a temperature of 39.6 C and has mild right costovertebral angle tenderness.

Macroscopic Urinalysis: Microscopic Urinalysis:

Characteristic Result

Color Yellow

Appearance Turbid

Leukocyte Esterase 3+

Nitrite Pos

pH 6.5

Protein Neg

Blood Neg

Specific Gravity 1.015

Ketones 1+

Glucose Neg

Bilirubin Neg

Questions:

1. How do you explain the appearance of the urine? How do you relate this to other findings?

2. What is the significance of the finding on physical examination?3. Is there a relation between the color of the urine and the diagnosis?4. What findings on microscopic urinalysis are of help in this case?5. What is the suspected diagnosis?6. What else should you do?

Characteristic Result

WBC/hpf >50/hpf

RBC/hpf 5-10/hpf

Casts Many WBC

Other Occasional transitional cells

Case 5

    A 34 year old Korean woman is admitted to the emergency room with the major complaint of "not feeling herself."  For the past week, she has been suffering from extreme fatigue and headaches, but did not feel the need to have it checked out until she has noticed that her vision is "a little fuzzy".  When asked if she is taking any medications, she responds a low dosage birth control, a women's daily multivitamin and prednisone for her systemic lupus erythematosus (SLE).

    An urinalysis is ordered.  The nurse notices that the urine has a "sweet" odor to it as she conducts the point of care testing.  The urinalysis results are:

Macroscopic Urinalysis:

Microscopic Urinalysis:

RBC 2-10/hpf WBC 0-5/hpf

Questions

1. What is the diagnosis of this patient?  What results from the urinalysis (both stix and microscopic) support your answer?2. Is it normal for a patient with SLE to have red and white blood cells in the urine?  Why or why not?  3. Does the stix result for leukocytes correlate with the microscopic findings?  Why or why not?4. Does the stix result for blood correlate with the microscopic findings?  Why or why not?

Case 6

 Color  Yellow

 Appearance  Clear

 Specific Gravity  1.010

 pH 7.0

 Protein  Trace

 Glucose  500 mg/dL

 Ketones Small

 Bilirubin Negative

 Blood  Negative

 Urobilinogen 0.2 mg/dL

 Nitrite  Negative

 Leukocyte Negative

A 5-year-old boy usually drove his mother crazy by running around the house all day long, but he has been lethargic for the past 2 weeks. On physical examination he is afebrile, but there is puffiness around his eyes.

Macroscopic Urinalysis: Microscopic Urinalysis:

Characteristic Result

Color Yellow

Appearance Hazy

Leukocyte Esterase Neg

Nitrite Neg

pH 6.0

Protein 4+

Blood Neg

Specific Gravity 1.020

Ketones Neg

Glucose Neg

Bilirubin Neg

Questions:

1. What key abnormal finding is present? Just what does the dipstick measure here, and what other test could be done on the urine?

2. What is suggested by the child's physical findings?3. What other laboratory test(s) would be useful?4. What is the diagnosis?

Characteristic Result

WBC/hpf 1-2/hpf

RBC/hpf None

Casts None

Other Occasional oval fat bodies