Chief Complaint: Dark Urine
Clinical History: Nathan S. was a 10 year old boy who was brought by his mother to a
community health clinic in a remote part of west Texas. The nearest physician was 80
miles away. When the physician assistant (PA) asked the reason for the visit, the boy’s
mother said, referring to his urine, “His water looks like Coca- Cola.” She went on to say
that she thought it might have been discolored the night before, but the light was poor and
she couldn’t be sure. This morning she notice the toilet water was discolored after he
urinated. She gave him juice and water and waited to observe for herself on his next
bathroom trip about two hours later. “He’s not making much water, “she added.
The PA asked the usual systems review questions. Specific questioning abuts drug
abuse, over the counter medicines, and exposure to toxins revealed nothing suspicious.
Nathan was not taking any prescribed or over the counter medicines. When asked about
any recent health problems, his mother revealed that he had been a picture of good health
and vigor except for “a cold and a bad sore throat” a few weeks earlier.
Physical Examination and Other Data: Vital signs were: Temperature 98.5F, heart rate
88, respirations 16, and blood pressure 145/92. Nathan was quiet and not in distress and
appeared to be of average height and weight. He did not appear anemic or jaundiced but
his face looked round and puffy. When asked abut his face, his mother said she’d noticed
it but thought it was because he was tired from staying up too late the last few nights with
his father, working on the farm where they lived. The remainder of the physical
examination was unremarkable. He had no rash, enlarged lymph nodes, or abdominal
The PA gave Nathen a big glass of water and collected some blood for the few
basic tests that could be done by the office assistant on clinical equipment. Hematocrit
was low (34mmHg) and blood glucose was normal. Sodium and potassium were normal.
BUN and creatinine were slightly increased. After two hours, Nathan passed a small
amount of dark brown transparent urine which tested strongly positive for both protein
and hemoglobin by routine dipstick tests. Urinary sediment was concentrated by
centrifugation. A moderate number of RBCs and a few red cell casts were noted, but they
didn’t seem enough to account for the strongly positive hemoglobin. No crystals or
WBCs were present.
Clinical Course: The PA was puzzled. The pieces didn’t seem to fit together, so she
called the hospital that managed the clinic and spoke to a pediatrician who said, “This is a
classic case of acute glomerulonephritis. I haven’t seen one in several years.” The
pediatrician outlined a treatment plan of salt restriction and therapy with diuretics and
antihypertensive medication with carefully monitoring of urine output. The PA dispensed
the drugs from the limited supply on hand and gave his mother a calibrated, disposable
urine cup, instructed her to measure Nathans urine output and call daily with the results.
His urine output was how initially but began to improve on the third day. Mother and son
returned a week later. His daily urine volume had returned nearly to normal, urine
hemoglobin and protein were less positive, and most of his facial swelling has
disappeared. On the follow up visit a week later, his blood pressure was near normal. A
blood specimen was collected and sent to the hospital to be tested for antistreptococcal
antibodies which were previously detected in high concentration.
1. Other than water and waste, name some important substances Nathan excreted in his
2. Nathans blood pressure was elevated. What structure and or hormones in his kidney
played a role in increasing his blood pressure? (3 points)
3. Nathans hematocrit was low, what is the norm range and why was his low? (3 points)
4. What were the principal nitrogenous wasted compounds in Nathans urine? (2points)
5. Did Nathan have proteinuria? Why? (2points)
6. His urine contained RBC casts, Of what importance was his finding? ( 3 points)
7. Why was Nathans face swollen? (2 points)
8. What caused the glomerulonephritis? (5 points)
9. Would the GFR be up or down? Why (4points)