CASE STUDIES AND CLINICAL SITUATIONS
Chapter 8
1. A 14-year-old boy who has recently recovered from a sore throat develops edema
and hematuria. Significant laboratory results include a BUN of 30 mg/dL (normal 8–
23 mg/dL) and a positive Streptozyme test result. Results of a urinalysis are as
follows:
COLOR: Red KETONES: Negative
CLARITY: Cloudy BLOOD: Large
SP. GRAVITY: 1.020 BILIRUBIN: Negative
PH: 5.0 UROBILINOGEN: Normal
PROTEIN: 3+ NITRITE: Negative
GLUCOSE: Negative LEUKOCYTE: Trace
Microscopic:
100 RBCs/hpf—many dysmorphic forms
5–8 WBCs/hpf
0–2 granular casts/lpf 0–1 RBC casts/lpf
a. What disorder do these results and history indicate?
A) Acute poststreptococcal glomerulonephritis
B) Rapidly progressive glomerulonephritis
C) Henoch-Schönlein purpura
D) Alport syndrome
b.What specific characteristic was present in the organism causing the sore throat?
A) Hyaluronidase
B) Streptolysin O
C) M protein
D) Protein C
c. What is the significance of the dysmorphic RBCs?
A) Anemia of infection
B) Glomerular bleeding
C) Autoimmune hemolytic anemia
D) Glomerular membrane thickening
d. Are the WBCs significant? A) Yes B) No
e. What is the expected prognosis of this patient?
A) Good recovery with treatment
B) Recovery requiring several blood transfusions
C) Gradual progression to nephrotic syndrome
D) May require renal transplant
f. If the above urinalysis results were seen in a 5-year-old boy who has developed a
red, patchy rash following recovery from a sore throat, what disorder would be
suspected?
A) Alport syndrome
B) Goodpasture syndrome
C) Wegener granulomatosis
D) Henoch-Schönlein pupura
2.
B.J. is a seriously ill 40-year-old man with a history of several episodes of
macroscopic hematuria in the past 20 years. The episodes were associated with
exercise or stress. Until recently the macroscopic hematuria had spontaneously
reverted to asymptomatic microscopic hematuria. Significant laboratory results
include a BUN of 80 mg/dL (normal 8–23 mg/dL), serum creatinine of 4.5 mg/dL
(normal 0.6–1.2 mg/dL), creatinine clearance of 20 mL/min (normal 107–139
mL/min), serum calcium of 8.0 mg/dL (normal 9.2–11.0 mg/dL), serum phosphorus
of 6.0 mg/dL (normal 2.3–4.7 mg/dL), and an elevated level of serum IgA. Results of
a routine urinalysis are as follows:
COLOR: Red KETONES: Negative
CLARITY: Slightly cloudy BLOOD: Large
SP. GRAVITY: 1.010 BILIRUBIN: Negative
PH: 6.5 UROBILINOGEN: Normal
PROTEIN: 300 mg/dL NITRITE: Negative
GLUCOSE: 250 mg/dL LEUKOCYTE: Trace
Microscopic:
>100 RBCs/hpf 2–4 hyaline casts/lpf
8–10 WBCs/hpf 1–5 granular casts/lpf
0–2 waxy casts/lpf 0–2 broad waxy
a. What specific disease do the patient’s laboratory results and history suggest?
A) Rapidly progressive glomerulonephritis
B) Nephrotic syndrome
C) IgA nephropathy
D) Diabetic nephropathy
b.Which laboratory result is most helpful in diagnosing this disease?
A) Creatinine clearance
B) Serum IgA
C) Serum calcium
D) Urine glucose
c.What additional diagnosis does his current condition suggest?
A) End-stage renal disease
B) Chronic glomerulonephritis
C) Focal segmental glomerulosclerosis
D) Acute renal failure
d.What is the significance of the positive result for urine glucose?
A) Diabetic nephropathy
B) Tubular damage
C) Polyuria
D) No significance
e. Is the specific gravity significant? Why or why not?
A) Yes; renal concentration is affected.
B) Yes; it should be higher due to the glucosuria.
C) No; the patient is forcing fluids.
D) Specific gravity is not significant
f. What is the significance of the waxy casts?
A) They are probably artifacts.
B) They indicate acute tubular damage.
C) They are associated with severe oliguria.
D) They indicate the patient is recovering.
3. A 45-year-old woman recovering from injuries in an automobile accident, which
resulted in her being taken to the emergency room with severe hypotension,
develops massive edema. Significant laboratory results include a BUN of 30 mg/dL
(normal 8–23 mg/dL), cholesterol of 400 mg/dL (normal 150–240 mg/dL),
triglycerides of 840 mg/dL (normal 10–190 mg/dL), serum protein of 4.5 mg/dL
(normal 6.0–7.8 mg/dL), albumin of 2.0 mg/dL (normal 3.2–4.5 mg/dL), and a total
urine protein of
3.8 g/d (normal 100 mg/d). Urinalysis results are as follows:
COLOR: Yellow KETONES: Negative
CLARITY: Cloudy BLOOD: Moderate
SP. GRAVITY: 1.015 BILIRUBIN: Negative
PH: 6.0 UROBILINOGEN: Normal
PROTEIN: 4+ NITRITE: Negative
GLUCOSE: Negative LEUKOCYTE: Negative
Microscopic:
15–20 RBCs/hpf 0–2 granular casts/lpf Moderate free fat droplets 0–5 WBCs/hpf
0–2 fatty casts/lpf Moderate cholesterol crystals 0–2 oval fat bodies/hpf
a. What renal disorder do these results suggest?
A) Chronic glomerulonephritis
B) Nephrotic syndrome
C) Minimal change disease
D) Focal segmental glomerulosclerosis
b. How does the patient’s history relate to this disorder? A) Sudden trauma B)
Multiple injuries C) Severe hypotension D) Previous condition; no relationship
c. What physiologic mechanism accounts for the massive proteinuria?
A) Basement membrane thickening
B) Increased membrane permeability from shock
C) Increased pressure on the glomerular membrane
D) Increased oncotic pressure
d. What is the relationship of the proteinuria to the edema?
A) Decreased capillary oncotic pressure
B) Increased capillary oncotic pressure
C) Decreased capillary hydrostatic pressure
D) Increased capillary hydrostatic pressure
e. What mechanism produces the oval fat bodies?
A) Massive edema
B) Clumping of filtered lipids
C) Tubular reabsorption of filtered lipids
D) Tubular necrosis from filtered proteins
f. State two additional procedures that can be performed to verify the presence of
the oval fat bodies and the fatty casts.
A) Polarized microscopy and Sudan III staining
B) Phase microscopy and Sudan III staining
C) Polarized microscopy and Hansel staining
D) Both A and B
4. A routinely active 4-year-old boy becomes increasingly less active after receiving
several preschool immunizations. His pediatrician observes noticeable puffiness
around the eyes. A blood test shows normal BUN and creatinine results and
markedly decreased total protein and albumin values. Urinalysis results are as
follows:
COLOR: Yellow KETONES: Negative
CLARITY: Hazy BLOOD: Small
SP. GRAVITY: 1.018 BILIRUBIN: Negative
PH: 6.5 UROBILINOGEN: Normal
PROTEIN: 4+ NITRITE: Negative
GLUCOSE: Negative LEUKOCYTE: Negative
Microscopic:
10–15 RBCs/hpf 0–1 hyaline casts/lpf
0–4 WBCs/hpf 0–2 granular casts/lpf
Moderate fat droplets 0–1 oval fat bodies/hpf
a. What disorder do the patient history, physical appearance, and laboratory results
suggest?
A) Nephrotic syndrome
B) Alport syndrome
C) Minimal change disease
D) Focal segmental glomerulosclerosis
b.What other renal disorder produces similar urinalysis results?
A) Alport syndrome
B) Focal segmental glomerulosclerosis
C) Acute poststreptococcal glomerulonephritis
D) Henoch-Schönlein purpura
c. What is the expected prognosis for this patient? A) Good B) Poor
5. A 32-year-old construction worker experiences respiratory difficulty followed by
the appearance of blood-streaked sputum. He delays visiting a physician until
symptoms of extreme fatigue and red urine are present. A chest radiograph shows
pulmonary infiltration, and sputum culture is negative for pathogens. Blood test
results indicate anemia, increased BUN and creatinine, and the presence of
antiglomerular basement membrane antibody. Urinalysis results are as follows:
COLOR: Red KETONES: Negative
CLARITY: Cloudy BLOOD: Large
SP. GRAVITY: 1.015 BILIRUBIN: Negative
PH: 6.0 UROBILINOGEN: Normal
PROTEIN: 3+ NITRITE: Negative
GLUCOSE: Negative LEUKOCYTE: Trace
Microscopic:
100 RBCs/hpf 0–3 hyaline casts/lpf
10–15 WBCs/hpf 0–3 granular casts/lpf
0–2 RBCs casts/lpf
a. What disorder do the laboratory results suggest?
A) Rapidly progressive glomerulonephritis
B) Goodpasture syndrome
C) Membranous glomerulonephritis
D) Wegener granulomatosis
b.How is this disorder affecting the glomerulus?
A) Capillary destruction by autoantibody
B) Thickening of the basement membrane
C) Interuption of membrane electrical charges
D) Deposition of immune complexes on basement membrane
c. If the antiglomerular membrane antibody test result was negative, what disorder
might be considered?
A) Goodpasture syndrome
B) Rapidly progressive glomerulonephritis
C) Wegener granulomatosis
D) Membranous glomerulonephritis
d. What is the diagnostic test for this disorder?
A) Urinalysis
B) FANA
C) ANCA
D) FTA-ABS
e. By what mechanism does this disorder affect the glomerulus?
A) Autoantibodies binding to neutrophils on vascular walls
B) Autoantibodies depositing on the basement membrane
C) Cytotoxic antibodies binding to vascular walls
D) Decreased platelets disrupting vascular integrity
6. A 25-year-old pregnant woman comes to the outpatient clinic with symptoms of
lower back pain, urinary frequency, and a burning sensation when voiding. Her
pregnancy has been normal up to this time. She is given a sterile container and
asked to collect a midstream clean catch urine specimen. Routine urinalysis results
are as follows:
COLOR: Pale yellow KETONES: Negative
CLARITY: Hazy BLOOD: Small
SP. GRAVITY: 1.005 BILIRUBIN: Negative
PH: 8.0 UROBILINOGEN: Normal
PROTEIN: Trace NITRITE: Positive
GLUCOSE: Negative LEUKOCYTE: 2+
Microscopic:
6–10 RBCs/hpf Heavy bacteria
40–50 WBCs/hpf Moderate squamous epithelial cells
a. What is the most probable diagnosis for this patient? A) Cystitis B) Acute
pyelonephrtitis C) Chronic pyelonephritis D) Acute interstitial nephritis
b. What is the correlation between the color and the specific gravity?
A) Diabetes inspidus
B) Dilute specimen
C) Gestational diabetes
D) Specimen is not urine
c. What is the significance of the blood and protein tests?
A) Urinary tract irritation from infection
B) Are usually elevated during preganancy
C) Are the result of strenuous exercise
D) Are associated with preeclampsia
d. Is this specimen suitable for the appearance of glitter cells?
A) Yes
B) No
e. What other population is at a high risk for developing this condition?
A) Female children
B) Male children
C) Elderly men
D) Nursing mothers
f. What disorder might develop if this disorder is not treated?
A) Chronic glomerulonephritis
B) Nephrotic syndrome
C) Acute pyelonephritis
D) Interstitial nephritis
7. A 10-year-old patient with a history of recurrent UTIs is admitted to the hospital
for
diagnostic tests. Initial urinalysis results are as follows:
COLOR: Yellow KETONE: Negative
CLARITY: Cloudy BLOOD: Small
SP. GRAVITY: 1.025 BILIRUBIN: Negative
PH: 8.0 UROBILINOGEN: Normal
PROTEIN: 2+ NITRITE: Positive
(SSA): (2+)
GLUCOSE: Negative LEUKOCYTE: 2+
Microscopic:
6–10 RBCs/hpf 0–2 WBC casts/lpf Many bacteria
>100 WBCs/hpf with clumps 0–1 bacterial casts/lpf
A repeat urinalysis a day later has the following results: COLOR: Yellow KETONES:
Negative CLARITY: Cloudy BLOOD: Small SP. GRAVITY: >1.035 BILIRUBIN: Negative
PH: 7.5 UROBILINOGEN: Normal PROTEIN: 2+ NITRITE: Positive (SSA): (4+)
GLUCOSE: Negative LEUKOCYTE: 2+
Microscopic:
6–10 RBCs/hpf 0–2 WBC casts/lpf Many bacteria >100 WBCs/hpf 0–1 bacterial
casts/lpf Moderate birefringent, flat crystals
a. What diagnostic procedure was performed on the patient that could account for
the differences in the two urinalysis results?
A) Catheterization
B) Bladder cystoscopy
C) Intravenous pyelogram
D) Creatinine clearance
b. Considering the patient’s age and history, what is the most probable diagnosis?
A) Cystitis
B) Acute interstitial nephritis
C) Acute pyelonephritis
D) Chronic pyelonephritis
c. What microscopic constituent is most helpful to this diagnosis?
A) >100 WBCs/hpf
B) Many bacteria
C) 0–2 WBC casts/lpf
D) Moderate flat crystals
d. What is the most probable cause of this disorder?
A) Untreated urinary tract infection
B) Dehydration
C) Urinary tract structural abnormality
D) Allergic reaction
e. How can the presence of the bacterial cast be confirmed?
A) Gram stain
B) Hansel stain
C) Culture
D) Polarizing microscopy
f. What is the most probable source of the crystals present in the sediment?
A) Powdered gloves
B) Radiographic contrast media
C) Urinary catheter particles
D) Degenerated WBCs
g. Without surgical intervention, what is the patient’s prognosis? A) Good B) Poor
8. A 35-year-old patient being treated for a sinus infection with methicillin develops
fever, a skin rash, and edema. Urinalysis results are as follows:
COLOR: Dark yellow KETONES: Negative
CLARITY: Cloudy BLOOD: Moderate
SP. GRAVITY: 1.012 BILIRUBIN: Negative
PH: 6.0 UROBILINOGEN: Normal
PROTEIN: 3+ NITRITE: Negative
GLUCOSE: Negative LEUKOCYTE: 2+
Microscopic:
20–30 RBCs/hpf 1–2 WBC casts/lpf
>100 WBCs/hpf 1–2 granular casts/lpf
After receiving the urinalysis report, the physician orders a test for urinary
eosinophils. The urinary eosinophil result is 10%.
a. Is the urinary eosinophil result normal or abnormal?
A) Normal
B) Abnormal
b. What is the probable diagnosis for this patient?
A) Acute tubular necrosis
B) Acute pyelonephritis
C) Chronic pyelonephritis
D) Acute interstitial nephritis
c. Are the increased WBCs and WBC casts in the absence of bacteria significant?
A) Yes
B) No
d.How can this condition be corrected?
A) Discontinue the methicillin.
B) Hydrate the patient.
C) Give the patient corticosteroids.
D) Both A and C.
9. Following surgery to correct a massive hemorrhage, a 55-year-old patient exhibits
oliguria and edema. Blood test results indicate increasing azotemia and electrolyte
imbalance. The glomerular filtration rate is 20 mL/min. Urinalysis results are as
follows:
COLOR: Yellow KETONES: Negative
CLARITY: Cloudy BLOOD: Moderate
SP. GRAVITY: 1.010 BILIRUBIN: Negative
PH: 7.0 UROBILINOGEN: Normal
PROTEIN: 3+ NITRITE: Negative
GLUCOSE: 2+ LEUKOCYTE: Negative
Microscopic:
50–60 RBCs/hpf 2–3 granular casts/lpf
3–6 WBCs/hpf 2–3 RTE cell casts/lpf
3–4 RTE cells/hpf 0–1 waxy casts/lpf
0–1 broad granular casts/lpf
a. What diagnosis do the patient’s history and laboratory results suggest?
A) Chronic glomerulonephritis
B) Acute renal failure
C) End-stage renal disease
D) Acute tubular necrosis
b. What is the most probable cause of the patient’s disorder?
A) Massive hemorrhage
B) Azotemia
C) Glomerular damage
D) Toxic substances affecting the tubules
c.Is this considered to be of prerenal, renal, or postrenal origin?
A) Prerenal
B) Renal
C) Postrenal
d. What is the significance of the specific gravity result?
A) Decreased renal concentration
B) Decreased glomerular filtration
C) Increased urine protein
D) Electrolyte imbalance
e.What is the significance of the RTE cells?
A) Continued blood loss
B) Tubular damage
C) Patient hydration is needed
D) Both A and B
f. State two possible reasons for the presence of the broad casts.
A) Tubular and decreased renal concentration
B) Decreased glomerular filtration and oliguria
C) Azotemia and increased urine protein
D) Tubular damage and oliguria
10. A 40-year-old man develops severe back and abdominal pain after dinner. The
pain subsides during the night but recurs in the morning, and he visits his family
physician. Results of a complete blood count and an amylase are normal. Results of a
routine urinalysis are as follows:
COLOR: Dark yellow KETONES: Negative
CLARITY: Hazy BLOOD: Moderate
SP. GRAVITY: 1.030 BILIRUBIN: Negative
PH: 5.0 UROBILINOGEN: Normal
PROTEIN: Trace NITRITE: Negative
GLUCOSE: Negative LEUKOCYTES: Negative
Microscopic
15–20 RBCs/hpf—appear crenated
0–2 WBCs/hpf
Few squamous epithelial cells
a. What condition could these urinalysis results and the patient’s symptoms
represent?
A) Cystitis
B) Renal lithiasis
C) Bladder carcinoma
D) Acute pyelonephritis
b.What would account for the crenated RBCs?
A) Catheter damage
B) Glomerular bleeding
C) High specific gravity
D) Septicemia
c. Is there a correlation between the urine color and specific gravity and the
patient’s symptoms?
A) Yes
B) No
d.Based on the primary substance that causes this condition, what type of crystals
might have been present?
A) Triple phosphate
B) Uric acid
C) Ammonium biurate
D) Calcium oxalate
e.What changes will the patient be advised to make in his lifestyle to prevent future
occurrences?
A) Decrease strenuous exercise in hot weather.
B) Increase water consumption.
C) Decrease consumption of dairy products.
D) All of the above.
11. State a disorder or disorders that relate(s) to each of the following descriptions:
a. A patient with severe lower back pain and microscopic hematuria is scheduled for
lithotripsy.
A) Cystitis
B) Renal glycosuria
C) Renal calculi
D) Chronic pyelonephritis
b. The patient exhibits pulmonary and renal symptoms and a positive ANCA test.
A) Henoch-Schönlein purpura
B) Goodpasture syndrome
C) Rapidly progressive glomerulonephritis
D) Wegener granulomatosis
c. A patient who tested positive for human immunodeficiency virus exhibits mild
symptoms resembling the nephrotic syndrome.
A) Minimal change disease
B) Focal segmental glomerulosclerosis
C) Fanconi syndrome
D) Alport syndrome
d. A 40-year-old patient diagnosed with systemic lupus erythematosus develops
macroscopic hematuria, proteinuria, and the presence of RBC casts in the urine
sediment.
A) Rapidly progressive glomerulonephritis
B) Acute poststreptoccocal glomerulonephritis
C) Nephrotic syndrome
D) Diabetic nephropathy
e. A 50-year-old patient diagnosed with systemic lupus erythematosus exhibits
symptoms of gradually declining renal function and increasing proteinuria.
A) Alport syndrome
B) Membranous glomerulonephritis
C) Minimal change disease
D) Nephrogenic diabetes insipidus
f. A patient who has taken outdated tetracycline develops glycosuria and a
generalized aminoaciduria.
A) Alport syndrome
B) Goodpasture syndrome
C) Fanconi syndrome
D) Acute interstitial nephritis
g. A patient known to form renal calculi develops oliguria, edema, and azotemia.
A) Acute renal failure
B) Renal lithiasis
C) Chronic glomerulonephritis
D) End-stage renal disease
h. A patient has a normal blood glucose and glucosuria.
A) Diabetic nephropathy
B) Nephrogenic diabetes insipidus
C) Alport syndrome
D) Renal glucosuria
i. A 6-year old boy with respiratory syncytial virus has macroscopic hematuria.
A) Minimal change disease
B) Acute poststreptococcal glomerulonephritis
C) IgA nephropathy
D) Alport syndrome