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Old 06-09-2011
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Kidney How to investigate this girl with kidney problem!

A 7-year-old girl is brought to the emergency room by her mother for “side pain.” The girl had been in her normal state of health until the night before, when she began to cry and complain of pain in her left side. Acetominophen did not help the pain, and the girl vomited three times during the night. At 4:00 am, her temperature was 38.8°C (102°F). No diarrhea, hematuria, or polyuria were reported. Her past medical history includes frequent “tummy aches,” croup at age 2 years, and a urinary tract infection at age 4 years. For the past 2 years, the girl has had episodes of nocturnal enuresis after having been toilet trained at age 3 years. On physical exam, you note a well-nourished girl at the 75th percentile for height and the 95th percentile for weight. The child appears ill and uncomfortable, curled with her knees in front of her on the stretcher. She has diffuse abdominal tenderness and left costovertebral angle tenderness. Vital signs were: T = 39.2°C (102.6°F), HR = 128 beats per minute, RR = 16 breaths per minute, BP = 122/73 mm Hg. The remainder of exam was within normal limits. A urine dipstick shows trace amounts of protein and “large” blood, a pH of 7.3; “moderate” leukocyte esterase and nitrates and was negative for glucose. A microscopic examination showed RBC casts and many polymorphonuclear neutrophils along with motile bacteria. The girl is admitted to the hospital. In addition to radiologic studies to evaluate for renal stones and ureter integrity, which of the following should be evaluated to prevent secondary complications of this girl’s condition?

Answer Choices
A. An evaluation of the girl’s family situation
B. Liver function tests
C. Platelet counts
D. Quantitation of serum fibrin split products
E. Serum ammonia levels
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This girl most possibly has PKD. Back or side pain, blood in the urine, kidney stones or urinary tract infections are all suggestive of PKD.

Seventy-five percent of people with PKD have cysts in the liver.

Approximately 4-8 percent of people with PKD have small aneurysms.

Most PKD families have an “autosomal dominant” inheritance pattern. In this type of inheritance, when a person with PKD marries an unaffected spouse, each child has a 50/50 chance of having PKD.

I was hoping to see ultrasound liver in the options. But it isn't there. I suppose option A means family history of kidney diesease or cerebral aneurysm.

So I'll go with A.
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A. An evaluation of the girl’s family situation
But how can we prevent secondary complications through that?
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Quote:
Originally Posted by mle guy View Post
A. An evaluation of the girl’s family situation
But how can we prevent secondary complications through that?
Following getting relavant history, need to proceed with tests such as brain MRA!

Yes. You're right-getting info won't prevent complications.
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Option E (Serum ammonia levels) is correct. This girl has a urinary tract infection (UTI) caused by Proteus mirabilis, a motile organism that commonly causes UTIs and renal stones and is unique among urinary tract pathogens in its splitting of urea to form NH4 and CO2. This raises the pH of the urine, making it a more hospitable environment for pathogens. Sometimes, infection with Proteus causes hyperammonemia and central nervous system manifestations. Assessing this patient’s serum ammonia levels would alert the physician to possible impending complications.

Option A (An evaluation of the girl’s family situation) is incorrect. There is no reason to believe that this girl’s urinary tract infection is related to abuse of any kind. Gonorrheal or chlamydial infection, however, would be an indication to contact Child Protective Services.

Option B (Liver function tests) is incorrect. There is no reason to believe that this girl has liver problems. Although Proteus infections cause elevated ammonia levels, this is not a product of impeded liver function, but rather is caused by the bacterium’s urea-splitting abilities, which releases NH4 as an endproduct.

Option C (Platelet counts) is incorrect. A platelet count would be a good idea if this girl were suspected of having thrombotic, thrombocytopenic purpura (TTP), which often has renal manifestations, or ideopathic, thrombocytopenic purpura. However, the absence of purpura or symptoms of thrombocytopenia (e.g., easy bruising) make these unlikely. There is a better explanation for the girl’s hematuria given the other findings.

Option D (Quantitation of serum fibrin split products) is incorrect. Elevated levels of D-dimer and fibrin split products would be seen with disseminated, intravascular coagulation, which would manifest itself with signs of bleeding, shock, and organ infarction. TTP (as mentioned in rationale C) would also lead to consumption of fibrin, but is not high on the differential in this case.

High-yield Hit 1
Other members of the Enterobacteriaceae are also implicated (Fig. 20.1). Proteus mirabilis is often associated with urinary stones (calculi), probably because this organism produces a potent urease, which acts on urea to produce ammonia, rendering the urine alkaline. Klebsiella, Enterobacter, Serratia spp. and Pseudomonas aeruginosa are more frequently found in hospital-acquired UTI because their resistance to antibiotics favors their selection in hospital patients (see Chapter 36).
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i did choose A too thinking it is pkd
but the answer is E
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Quote:
Originally Posted by miss patho View Post
i did choose A too thinking it is pkd
but the answer is E
WOW! I didn't expect that!

All boxes for PKD are ticked!
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Good questions missi
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