Case study: renal Flashcards
A 6 month old girl presents with 3d of fever (>39o), vomiting, poor feeding, being unsettled and having strong smelling urine.
Examination showed RR 40, HR 150, no focal findings in the chest, abdomen, ears or throat
- Diagnosis and differential?
- Investigations
- Management?
- Urinary tract infection
?LRTI/ Pneumonia
Consider other abdominal foci - Urine dipstix, microscopy and culture
Consider FBC/ CRP, CXR, Throat swab if negative - Admit, IV 3rd gen.
Cephalosporin or co-amoxiclav
Keep well hydrated
Follow-up Renal USS/ DMSA +/- MCUG
ccx of UTI?
septic shock
more common in infants
1st line investigation of UTI?
Clean catch/ mid stream recommended (practical?)
Pads and bags used (generates false positives)
SPBA/ Catheter (invasive/ specialist decision)
Treatment is priority if acutely unwell
what to look for in investigation of UTI?
Dipstix: nitrites/ Leucocyte esterase activity
Pyuria (some labs give provisional report)
Bacturia (takes 48h)
treatment of lower tract UTI?
Oral trimethoprim/ co-amoxiclav
treatment for Plyonephritis (well):
Oral antibiotics (not infants)
treatment for Pylonephritis (unwell):
IV 3rd gen. Ceph/ Co-amox
ccx of UTI?
reflux (VUR)
renal scarring
follow up after UTI?
Renal USS (hydronephrosis/ kidney size) (All <3y)
DMSA (isotope scan for scarring)
MCUG (younger) MAG3 (older) for reflux if scarred
A 3y old boy presents with 5 days of vomiting and bloody diarrhoea. He is tolerating oral fluids and recently visited a petting zoo
Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort
- Diagnosis, causes
- potential complications?
- Investigation
- management?
- Gastroenteritis (Ecoli 0157, Campylobacter, Salmonella, shigella, yersinia),
?IBD if prolonged
ecoli- bloody diarrea
- Potential Haemolytic Uraemic Syndrome
- Stool cultures (bacterial and viral)
Urine dipstix and blood pressure
Check blood count and film, U+Es, LDH - Good hydration (low threshold for IV if HUS risk)
Monitor urine output/ fluid balance
Monitor bloods (HUS can present 10-14d later)
May require dialysis +/- blood/ platelet Tx
Antibiotics not indicated
Parental information
Notify public health
how to asses hydration?
Alertness/ conscious level? Fontanel (if present)- sunken or level? Sunken eyes? Dry or moist tongue/ lips? Heart rate? CRT? Resp rate? Peripheral warmth or coolness? (hands / feet) Skin turgor? Weight loss/ urine output- ?difficult to quantify
When does HUS develop?
10-15% of Ecoli-0157 cases
triad of HUS?
Microangiopathic haemolytic anaemia (fragments)
Thrombocytopenia (platelet consumption/ bruising)
Acute renal failure (potential multi-organ involvement)
most common cause of acute renal failure?
Most common cause of acute renal failure
Most commonly post diarrhoea
Verotoxin producing E coli (O157 commonest) (~15%)
Shigella (Shiga toxin)
A 9y old boy is brought is because parents are concerned that he still wets the bed most nights.
He has no fever and abdominal/ spinal/ neuro examination is normal.
- What is the likely diagnosis?
- What other information do you need to gather?
- Investigations?
- Management options?
- Primary nocturnal enuresis (~15% 5y, 5% 10y, B>G)
(Syn. Intermittent nocturnal incontinence)
2.Day time dryness? Wetting? Urgency? Frequency?
Fluid consumption: volume and timing
Constipation/ stool pattern
3.
Urine dipstix +/- Culture, ?USS for pre/ post volumes
4. Increase daytime fluids (water not juice) Decrease night fluids Pads and alarms (bladder training) Consider desmopressin +/- oxybutynin
