Case Study 21: Dark Urine in an Adult - CRASH! Medical Review Series
HTML-код
- Опубликовано: 15 фев 2023
- For just $1/month, you can help keep these videos free! Subscribe to my Patreon at / pwbmd
(Disclaimer: The medical information contained herein is intended for physician medical licensing exam review purposes only, and are not intended for diagnosis of any illness. If you think you may be suffering from any medical condition, you should consult your physician or seek immediate medical attention.)
(On Thursday of February 16, 2023). On the Matter of Case Study #21 on the Medical Scenario of Dark Urine with Anemia: 1) Vitals: a) Blood Pressure at 109/68, b) Heart Rate at 102 (Tachycardia); c) Respiration Rate at 14; Temperature is 97.5 Degrees Fahrenheit; 2) Physical Examination (Px): 1) General Assessment is Fatigue Predominant; 2) Skin is Positive for 1) Mild Pallor (Anemia); 2) Normal Turgor and 3) Negative For Skin Lesion of Rash; 3) Head, Ears, Nose and Throat (HEENT) is Normocephalic, Absent of Injury, Pupils are Equal, Round, And Reactive To Light and Accommodation (PERRLA); Conjunctival Pallor (Sign of Anemia); 4) Chest and Lungs are Clear to Auscultation; 5) Cardiovascular Review is Regular in Rate and Rhythm (RRR) and No Heart Sounds (Murmurs and Gallops); 6) Abdomen Assessment has Non-Tender, Non-Distended (NT/ND), Soft, and Asplenomegalic; 7) Spin and Extremities has No Costovertebral Angle (CVA) Tenderness (Kidney Pathology Negative Herein) with Intact Peripheral Pulses, and No Edema Manifested; 8) Neurological Review has No Focal Signs, Sensation Intact, Deep Tendon Reflexes (DTRs) Intact, and Normal Strength; SSx: DDx: 1) Anemia, Therefore: 1) Iron Deficiency (Most Common) would Have Fatigue, Pallor, History of Diathesis or Hemorrhage, Menorrhagia in Females; 2) Nutritional Deficiency (Vitamin B 9, B12) is common In Vegan/Vegetarian Diets, Alcoholics and can often have Neurologic Symptoms if Not outright Psychiatric Manifestations (Depression, Anxiety and Psychosis); 3) Hemolytic Anemias: 1) Intrinsic Anemias: a) Hereditary Spherocytosis (PBS) has Jaundice and Splenomegaly (CVA+); b) Elliptocytosis is an Rare Autosomal Dominant disease (PBS with Ovalocytes, Elliptocytosis); c) G6PD Deficiency (Male, African Stock) is an Autosomal Recessive Congenital Disease; d) Pyruvate Kinase Deficiency (PKD), A Chronic Anemia of X-Linked Pattern of Inheritance; 2) Paroxysmal Nocturnal Hemoglobinuria (PNH) is an Acquired, Immune-Mediated Hemolytic Anemia (Association to Aplastic Anemia) due to Somatic Variation in PIG-A gene; 3) Microangiopathic Hemolytic Anemia (MAHA) will have Schistocytes In PBS. Neoplasia, Hemolytic Uremic Syndrome-Thrombotic Thrombocytopenic Purpurea (HUS-TTP) and Thrombosis; 4) Autoimmune Hemolytic Anemia (AIHA), Warm Type will Have Coombs Test Positive, Splenomegaly in a Young Patient (Spherocytes on PBS); 5) Cold Agglutinin Disease (CAD) with Acrocyanosis (Feet, Hands and Face) and Raynaud Phenomenon (Acral Blanching, Cyanosis, Erythematous Process Pattern) and a Negative Coomb's Test in the Scenario of History of Viral Infections; 3) Renal Causes: 1) Post-Streptococcal Glomerulonephritis (PSGN) has an Infection three Weeks Prior and Group A Beta-Hemolytic Streptococcus (Streptococcus pyogenes) with Casts and RBCs in Pediatric Subjects; 2) Myoglobinuria is Rhabdomyolysis (Recent High Exertion Exercise) and Cola-Hue Urine (SSx: Muscle Pain, Fatigue, Fever, Nausea, Delirium [Geriatric Subjects]); 3) Adult Polycystic Kidney Disease (Hypertension, CVA+, Hematuria) is with History of Autosomal Dominant Inheritance (RBCs, Casts, Flank Pain); 4) Renal Cell Carcinoma (RCC) Has Hematuria, Flank Pain, CVA+, Fatigue, Anorexia, Cachexia, Fever, Sweats, and Hypertension; 4) Diagnosis (Dx): 1) Urinalysis (To Visualize the Urine); In this Case, there is Dark Urine (Cola-Colored Urine), Hemoglobin Positive, Hemosiderin in Microscopy, No Cells within Urine, nor is there any Casts (Nephritic/Nephrotic Syndrome Negative) or ; 2) Complete Blood Count (CBC for Anemia and other Counts) With Peripheral Blood Smear (PBS for Morphology): a) WBCs are at 6,500/mm3 is WNL; b) Hemoglobin at 9.5 mg/dL is Low; c) Hematocrit is at 29.1% and is Low Confirming Anemia Of Clinical Suspicion; d) Platelets are at 233,000/mm3; e) Mean Corpuscular Volume (MCV) at 74 um2; f) Where PBS is Unremarkable (Morphology is non Diagnostic); 3) Basic Metabolic Panel (BMP) for Electrolytes, Urea and General Kidney Function is WNL; 4) Iron Studies: 1) Serum Iron is Low; 2) Ferritin is High; and 3) Total Iron Binding Capacity (TIBC) is High; 5) Reticulocyte Count is High If there is Compensation or Low If Pathology Localized to the Bone Marrow; In this Case, Count is High at 3.2%; 6) Unconjugated Bilirubin Test is High at 1.6 mg/dL; 7) Haptoglobin is Low (Liver Disease Negative with Anemia); and 8) Serum Lactate Dehydrogenase (LDH) is High at 400 IU/L; 9) Working Diagnosis of Hemolytic Anemia (With Iron Deficiency) due to Positive LDH, Haptoglobin Low, and High Unconjugated Bilirubin; 10) However, Coombs Test (To Assess For Possible Mechanism of Disease) for Autoantibodies and is Herein Negative (No Autoimmunity); 11) Flow Cytometry to Identify CD55 and CD59 (Glycosylphosphatidylinositol or GPI) are Minimally Expressed and is Indicative of PNH; 5) Treatment (Tx): 1) Eculizumab (Monoclonal Antibodies Biologics Drug Class) Also known as Solaris by Tradename Standard; Eculizumab, is a Human Monoclonal Antibody Complement (C5) Inhibitors; 2) Meningococcal Vaccination (Prophylaxis); 3) PO Iron Supplementation (Iron Deficiency on CBC); 4) Repeat Hemoglobin at Three Months (3); and 4) Referral to Hematology as the Management of PNH is a Specialty Diagnosis to Begin with; 5) Transfusion is Warranted if Hgb is Less than 8.5 mg/dL; 6) Thrombosis Prophylaxis Via Aspirin for Pregnant Patients (or LMWH); and Life Long Warfarin Therapy for any Subject with History of Thrombosis; 6) Pathology of Paroxysmal Nocturnal Hemoglobinuria (PNH) is Hypoxia-Induced Hemolysis due to Complement-Mediating Cytoplasmic Markers of Erythrocytes (CD55 and/or CD59) via Somatic Genetic Variation of PIG-A Gene (Hemoglobinuria occurs in 25% of Cases of PNH as the salient Complaint); The Sudden and Acute Episodes or Paroxysms last on Average 3-5 Days with Anemia of Hemolysis (Blood Loss Anemia), Erectile Dysfunction, and Dysphagia (Smooth Muscle Dystonia) are Possible Signs and Symptoms; 7) Complications (Cx): 1) Thrombosis of Hepatic and Intra-Abdominal Veins; 2) Aplastic Anemia (Pancytopenia although this can be the actual Presentation of PNH); 3) Budd-Chiari has Right Upper Quadrant (RUQ) Tenderness, Hepatomegaly, and Ascites; 4) Cerebral Thrombosis has Increased Intracranial Pressure (ICP) manifesting at times as Headache, Nausea/Vomiting, or Papilledema; 5) Deep Vein Thrombosis (DVT) has Lower Extremity Swelling due to Clots therein (Venous Stasis), Change of Color of the Skin, Pitting Edema; Goodness, My first PNH Management. Well, just kidding. The Subject was Actually Within Malignancy Stage of the Pathogenesis and furthermore coupled to a rare Myelophthisic Anemia (MA). You Never have seen it all. MD Paul W. Bolin, es geht sehr gut aber man auch muss vermehren sich wie er vermehrt Anderen. Heil!
you are the best. Thanks Dr.Bolin
Wow. Beautiful explanation. Thank you 🙏🏻
Thanks alot doctor for your informative channel
Always keeping up with a blessing called Dr Bolin :)
We silly brits really do like our extra vowels. Oesophagus, haemoglobin, diarrhoea. Why? Because it's *fancy*!
Fancy, and more in line with the original words from Greek and Latin!