som
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A 60-year-old man comes to the physician's office because of fatigue and hematuria. His past medical history is significant for fatty liver, gout, and anemia. He has smoked two packs of cigarettes daily for 40 years. He is a heavy alcohol drinker. His last visit to his physician was 1 month ago for the 'flu'. His temperature is 37.1C(98.9F), blood pressure is 145/90mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows no abnormalities. Dipstick testing is positive for hematuria.
Laboratory studies show:
Urinalysis
Glucose-Negative
Ketones-Negative
Leukocyte esterase-negative
Nitrites-Negative
WBC-1-2/hpf
RBC-1-2/hpf
Casts-Epithelial cell
Serum chemistry:
Serum Na-140 mEq/L
Serum K-5.0 mEq/L
Bicarbonate-20 mEq/L
BUN-36 mg/dL
Serum creatinine-3.4 mg/dL
Which of the following is the most likely diagnosis?
A. Post infectious glomerulonephritis
B. Hepatorenal syndrome
C. Rhabdomyolysis
D. Renal cell cancer
E. Bladder cancer
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| cbenitesch
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D)
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| tolito
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E. with obstruction.
his history of smoking increases his risk of bladder ca.
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| GDS2008
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C. Rhabdomyolsis (alcoholic with a recent stress, hematuira on dipstick without significant RBCs on urinalysis + the most important evidence of intrinsic renal failure i.e. high serum creatinine + BUN/Cr ratio of 1:10)
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| frank100
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as far as I rmember, yes the answer is rhabomyolisis. But is too tricky to just look at it and acream the answer in your head. This is one of those questions made to learn from the options rather than from the answer.
e.g:
from option D I got the triad of renal cancer: fever, hematurea and pain in flank
bladder cancer presents with hematurea that is painless
options A and B are not likely in this setting.
and from the answer the only thing I got was: suspect rhabdomyolisis in alcoholics.
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| frank100
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cancer is the great simulator, so D and E, are still a big one here, since there are no solid clues. of course when you read the question the last thing comes to your head is to calculate the BUN/CR difference. so next time (on the real test), we all be more prudent when reading a question like this...and choose the right answer...
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| som
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painless hematuria here is a major distractor. it drags into the pit when we are doing que in a hurry. look for the clues here: alcoholism, increased creatinine, hematuria with no or very little rbc on m/s
nice expln GDS2008, frank100.
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| som
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some things to note;
1)african american with painless hematuria- suspect sickle trait
2)painless hematuria+fever+flank pain in an elderly male- renal cell ca
3)painless hematuria in an alcoholic- rhabdomyolysis
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| MAZI
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rhabdomyelysis
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| Sea_gull
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som wrote:
some things to note;
1)african american with painless hematuria- suspect sickle trait
2)painless hematuria+fever+flank pain in an elderly male- renal cell ca
3)painless hematuria in an alcoholic- rhabdomyolysis
Dear Som
What do mean by "painless hematuria in an alcoholic- rhabdomyolysis"? Honestly I could not understand .Would you please explain "Hematuria"?
GL
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| som
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heyy sea_gull, what I mean is that an alcoholic pt when presents with painless hematuria, like in above case(ofcourse with some abnormak labs), suspect rhabdomyolysis.
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| Sea_gull
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som wrote:
heyy sea_gull, what I mean is that an alcoholic pt when presents with painless hematuria, like in above case(ofcourse with some abnormak labs), suspect rhabdomyolysis.
Dear Som
There is no hematuria in Rhabdomyolysis.This is what I am surprised .What is the source of and cause of blood in the urine in Rhabdomyolysis? I could not understand
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| sheena2005
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there is discoloured urine in rhabdomyolysis because of breakdown of myoglobin
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| sheena2005
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it's myoglobinuria rather then hematuria
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| Isther
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Clinically (just looking at it) is is impossible to distiguish between myoglobinuria and hematuria, several clinicians call it hematuria until the lab can make the difference... unless the whole clinical picture strongly suggests that it is a myoglobinuria indeed.
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| study_ing
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wud u call it myoglobinuria if urine is RBC positive...
this was one thinking poin tfor me..
however assuming the pt complains of gross hematuria, 1-2 rbcs per HPF i think wud be insufficient to coz it grossly.
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| Sea_gull
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Isther wrote:
Clinically (just looking at it) is is impossible to distiguish between myoglobinuria and hematuria, several clinicians call it hematuria until the lab can make the difference... unless the whole clinical picture strongly suggests that it is a myoglobinuria indeed.
Would you give the name of any "Authenticated clinician " who calls every "red color" urine as "Hematuria"???
GL
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| Isther
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Dude...what is your point???
an alcoholic with red urine can be hematuria and myoglobinuria... anyway you need to check it... I don't see any biggy on this one.
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| Sea_gull
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Isther wrote:
Dude...what is your point???
an alcoholic with red urine can be hematuria and myoglobinuria... anyway you need to check it... I don't see any biggy on this one.
Dear
What should I check it.Myoglobinuria is by itself an entity.It does not contain Hematuria.How can you call it as "Hematuria"? I do not understand.You are referring to clinicians who call every red color urine as "hematuria".
GL
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| Isther
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Well dear, you have a point...
so how do you suggest to call the red urine until you have confirmation of its nature... just "red urine"  ... as much as an independent entity that myoglobinuria could be, it is still very hard to name it as such just to looking at it even with some clinical info...
Well, this is completeley irrelevant to the question though... but I enjoy this type philosophical disagreement--- 
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