IPCEA Family Medicine Teaching Case
——Diagnosis and Treatment in Family Medicine to a Boy with Asymptomatic Hematuresis

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A five-year old boy，came to our clinic with his mother,the mother complained that urine occult blood has been found in her son for 10 months.She showed us a lot of lab tests reports from many different hospitals,she looked so worried because no doctor could tell her the reason of her son′s urine occult blood,and she also wanted to know if there is a way to cure her son′s symptom.

1 Medical records

This boy was hospitalized in September 2012 because of red rash all over his body,and his final diagnosis of rash was ′Urticaria′.The boy received urine routine microscopic analysis tests several times during his hospitalization,all these urine tese indicates:Positive of urine occult blood.But he had no any discomfort or any symptoms of urinary tract,such as frequent micturition and urgent urination,so doctors didn′t prescribe him any medication,just suggested follow-up after leaving hospital.

The mother had to take the boy to see doctors for rechecking urine every 1 or 2 months,and they have ever seen different doctors of different hospitals in recent 10 months.

Three months ago，a pediatrician ordered urine bacterial cultures for this boy in three consecutive days which indicats：Gram——positive bacterium>10×104cfu/ml.Then the doctor make a diagnosis as urinary track infection.But that doctor didn′t prescribe any medicine for this child based on his asymptomatic situation.

So far,the boy has grown healthily since last year after discharge from the hospital.He had no edema of eyelids,no edema of lower extremities,no frequent urination or urinary pain no dysuria,no allergies to food and medicine.His appetite and sleep are normal,and he has been vaccinated on time.

The mother worried very much about the positive result of urine culture.She also wanted to find out the cause of her son′s hematuresis,and whether the child′s development would be affected in the future.So she came here again to see us,some family physicians.

DR.Harry Morric saw the patient and his mother with us.

2 Teaching process

2.1 According to our regular training,one of our trainee doctors took the medical history within the prescribed time,and reported to the trainer,Dr.Harric.

2.2 Put forward the supplement questions by the trainer and other trainees.

2.3 Preliminary assessment.

2.4 Physical examination.

2.5 Primary diagnosis and corresponding treatment.

2.6 Humanistic care and health education.

3 Discussion and analysis

3.1 To explore the reasons of hematuresis,and to supplement the medical history.

3.1.1 Did the boy have any other diseases or take any special medicine before he was hospitalized? Not all red urine can be hematuresis,urine colour can be changed to red or brown by some food and medicine,such as rhubarb,phenolphthalein,rifampin,etc.Some medicine can lead to hematuresis,for instance,cyclophosphamide,allopurinol.

3.1.2 Could we know the accurate diagnosis of his grandmother′s kidney disease? Is the boy′s symptom connected with genes?

3.1.3 Why did the boy only have the urine culture,not susceptibility testing?

3.1.4 The most common bacteria in urine culture of urinary tract infection is nonspecific gram-negative bacteria,such as E.coli,accounts for 85%.But in this case,the result showed gram-positive bacteria positive,thus we have to consider whether there was a pollution specimen or the nonstandard operation urine specimen.

3.2 Preliminary assessment

3.2.1 Characteristic of hematuresis source:A.Renal lesions:total hematuria,the colour was dark brown,and often with dull pain of renal area or renal colic.B.Bladder lesions:terminal hematuria,the colour was red,and often with micturition unwell symptom.C.Prostate and urethra disease:the colour was red,prostate and anterior urethra disease were terminal hematuria,but posterior urethra disease was initial hematuria,and both of them often with urgency,frequent urination and urinary pain.

3.2.2 The cause of hematuresis:A.Urogenital system:nephritis,kidney stone,tumor,trauma,lesions,etc.B.Systemic disease:hematopathy,infectious diseases,Connective tissue and allergic diseases,cardiovascular system diseases,metabolic disease,and else.C.Urinary tract adjacent organ diseases:inflammation or tumor.D.The other reasons:sports or other unknown reasons.

3.2.3 Assessment A.Nephritis? IgA Nephropathy?most patients have some discomfortable symptom,such as fever,chills,lumbar acid and bladder irritation syndrome,disease development was rapid during the short time.According to this boy′s medical history,his condition didn′t get worse in 10 months.B.Urinary tract infection?most likely,but there were not with bladder irritation syndrome,so where is the specific infection place? C.Urinary system trauma? usually caused by serious external force,thus it can be ruled out.D.Congenital genitourinary abnormalities? Urinary tract obstruction?Clinical evidence does not support,and it can be excluded by a simple noninvasive auxiliary examination.E.Exercise-induced hematuria? Drug-induced hematuria? The boy didn′t do any strenuous exercise and no medication history,so it can be ruled out.

3.3 Physical examination Physical examination is a basic skill for a doctor which can not be neglected,and the most important step before we diagnose disease is that we should confirm which assessment is correct through the examination.

3.3.1 General examination:T 37 ℃,HR 75 bpm,P 21 bpm,Ht 116 cm,Wt 18 kg.Generally in a good condition,developing normally.No congestion on pharyngeal.No tonsils swelling.Lungs are clear.Heart are unremarkable.No masses or tenderness in abdominal.No renal percussive pain.

3.3.2 Male urogenital system examination：penis exam showed redundant prepuce,and urethral meatus slightly redness and swelling with a little discharge could be seen when we turned over his prepuce.Scrotum normal.

3.4 Diagnosis:urethral meatus infection Then we questioned the medical history,the mother told us that none of doctors examined urogenital system for the boy since last year in both inpatient and outpatient.And the parents never know how to clean the boy′s genital.According to this,we got the clear diagnosis immediately.Finally,the mother′s worry and confusion are eliminated.

3.5 Treatment We suggested the parents to help the boy turn over his genital prepuce and clean it with 1% iodophor every day.At the same time,we guided the boy′s mother how to teach her son to wash his genital by himself every time when he takes a shower.

4 Follow up and result

The patient was treated for 1 week and came back to our clinic for rechecking.Physical examination showed urethral meatus was normal,no redness and swelling.Urine routine:occult blood(-),WBC(-).We confirmed again that the mother could give the good advice to her son for cleaning his genital.And we also educated the mother how to concern about the boy′s growth.

5 Thinking and conclusion

5.1 This is a typical complex and simple case,which could be encountered in our clinic,so it gives a strong warning for us.When the patients come to our clinic with a big pile of laboratory result and diagnosis in many different hospitals,we usually only look at the paper or auxiliary examination report,then we would diagnose or prescribe.But obviously,we forget to do physical examination,which is very necessary for every patient.For instance,if we ignored the most basic medical skills for this child patient,then we will lose the opportunity to find out the correct diagnosis.We should abide by the diagnosis and treatment program strictly with rigorous medical attitude.

5.2 Considering with genitourinary system disease,we have to check the genitals for each patient as a doctor,especially for male patient.For a little boy,we should consider whether redundant prepuce causes urinary tract infection.And we need to educate the parents how to pay attention to the child growth.As female patients,especially for little girls,we also have to consider the relationship with vaginal,infant ilvulvitis causes micturition unwell as the most important reason.

5.3 As a family physician,we should abide by the principle of patient-centered,avoid unnecessary auxiliary examination,alleviate patients′ suffering,mental pressure and lighten the financial burden of patients as much as possible.In this case,the boy′s family was not rich,we eliminated their worry for nearly 10 months through the basic physical examination,and the child and his mother didn′t need to see doctors in many different hospitals.We are so proud of us as family physicians.