Fred Gong

Case Write up #2 - Hematuria

CC: 62-year-old female presents with blood in the urine.

HPI: 62-year-old female with a past medical history of hypertension and vertigo presents to the
ED with a 1-day history of blood in the urine. She recently drove to Delaware to spend time with
family and the morning of her drive back to NY, she noticed her urine was red and blood tinged.
Her next urination was the same color, however subsequent ones after were a normal, yellow
tinged urination. She denies vaginal bleeding, spotting, or blood outside of urination. She was
concerned and came to the ED right when she got back to NY. The patient also endorses fever,
chills, and left lower extremity swelling. She denies dysuria, urgency, frequency, flank pain,
abdominal pain, nausea, vomiting, vaginal bleeding, or dizziness. She does not endorse having
heavily exerted herself or having eaten beets recently. She is menopausal, sexually active with
one partner, and denies vaginal dryness or bleeding after sex.

ROS:
General: endorses fever and chills, denies fatigue, malaise, or weight changes
HEENT: denies headache, vision changes, rhinorrhea, or sore throat
CV: denies chest pain or palpitations
Pulmonary: Denies SOB, dyspnea, cough, or sputum
GI: denies nausea, vomiting, abdominal pain
GU: endorses hematuria, denies dysuria, urgency, or frequency
MSK: endorses left lower leg edema, denies weakness or numbness
Derm: denies rashes, petechiae, or purpura
Neuro: denies seizures or AMS
Psychiatric: denies psychiatric history
Endocrine: denies polydipsia or polyuria

EMS Course: no EMS services used.

ED Course: Hemodynamically stable. Labs significant for hematuria and pyuria on UA, pending
urine culture. Creatinine within normal limits. WBC and RBC within normal limits.
Interventions: 1g ceftriaxone and 1L bolus LR.

PMH:
Hypertension (unknown date of diagnosis)
Vertigo (Has not had episode in years)

PSH: no surgical history

Allergies: No known drug, food, or environmental allergies

Medications:
Atenolol 50 mg oral tablet, 1 tab orally once a day

Enalapril 10 mg oral tablet, 1 tab orally once a day

Aspirin 81 mg oral tablet, 1 tab orally once a day

Meclizine 25 mg oral tablet, PRN 2 tabs orally 3 times a day

Pharmacy: Silver Rod Drugs 5105 Church Ave, 718-922-3400

PCP: Jerry Ubuevbo, 718-928-7575

FH: 1 brother died of stomach cancer, 1 brother died of prostate cancer, 1 sister hypertension.

SH: No smoking, drinking, or recreational drug use. Worked as home care aide before COVID
and is currently not working. Lives at home with kids. Performs all activities of daily living on
her own, does not require assistance. Sexually active with one long term partner. Has not had a
period in years - menopause.

DVT ppx: pharmacologic - heparin 5000U subQ q12

Diet: heart healthy diet
Disposition: home
Code status: full code
Health care proxy: SLR - daughter

Vitals:
T 98.4 (oral)
HR 83 bpm
R 16 bpm, 100% on RA
BP 128/65
BMI 29.8

PE:
General: AAOx3, no acute distress, appears stated age
HEENT: PERRLA, no conjunctival pallor, no lymphadenopathy
Respiratory: normal breath sounds on room air
Cardiovascular: Normal s1, s2. No murmur, rub, or gallop.
GI: soft, NT, ND. No hepatosplenomegaly. Bowel sounds present. No suprapubic tenderness, no
CVA tenderness bilateral.
GU: GU exam was not performed
Extremity: Left LE non-pitting edema > 3cm compared to right LE, no skin abnormalities

Labs:
CMP: Na- 139, K- 4.1, Cl- 103, CO2- 25, BUN- 15, Cr- 0.7, Glucose- 119, Protein- 7.8,
Albumin- 4.5, Alkaline Phosphatase- 67, AST- 19, ALT- 14, Calcium- 9.8, Bilirubin total- 0.4,
CK- 72, TSH- 2.03

CBC: WBC- 9.61, HGB- 13.2, HCT- 39.6, PLT- 162

UA: cloudy, protein: 15 mg/dL, nitrites: negative, LE: large, RBC: 155, WBC: 586, WBC-C:
many, few bacteria, SQEP: few

UC: pending

COVID: negative

Imaging: no imaging was performed or ordered

Assessment: 62-year-old female with a past medical history of hypertension and vertigo who
presents to the ED with two episodes of blood in the urine and left lower extremity swelling.
Patient denies flank pain or dysuria. Patient is hemodynamically stable, PE shows unilateral left
lower leg swelling, no suprapubic tenderness or CVA tenderness, UA shows pyuria and
hematuria, and WBC, RBC, and creatinine within normal limits. Urine culture is pending. Patient
most likely has UTI due to pyuria and hematuria on UA however given lack of dysuria,
frequency, urgency, and pending UC, GU cancers should be considered as well.

Differential Diagnosis:
1. UTI
a. Hematuria and pyuria on UA points us towards the diagnosis of UTI. Urine
culture will help confirm the diagnosis, guide antibiotic selection, and is pending.
The patient denies common symptoms of UTI such as dysuria, frequency, and
urgency. Although these symptoms are not necessary for confirmation of UTI, our
suspicion for other sources of painless hematuria must be explored.
2. Urologic Cancer (Bladder)
a. Painless hematuria is most frequently caused by bladder cancer. Although cancer
of the bladder, kidney, or ureter can cause painless hematuria, bladder cancer is
by far the most common of the three. Her UA with hematuria and pyuria can be
explained by a UTI, however urine culture is still pending. Risk factors for
bladder cancer include tobacco smoke and occupational toxins all of which seem
to be absent from our patient.
3. Vaginal/Endometrial bleeding
 a. Hematuria can often be confused for vaginal bleeding. The most serious etiology
of post-menopausal bleeding is endometrial cancer. Bleeding can also occur from
the vulva or anywhere along the vaginal canal. However, she only noticed blood
while urinating and denies spotting or bleeding otherwise. She also denies vaginal
dryness or pain during sex.
4. Kidney Stones
a. Kidney stones can also cause hematuria. However, kidney stones are often
associated with renal colic, CVAT tenderness, groin pain, nausea, and vomiting.
Her clinical presentation makes this diagnosis highly unlikely and is more
consistent with a UTI.
5. Glomerular Bleeding
a. Glomerular disease can present with gross hematuria. However, UA would show
significant proteinuria and RBC casts which were not present.

Problem List:
1. Hematuria, UA showing pyuria and hematuria
a. Ceftriaxone 1g per day for 3 days; empiric treatment for presumed UTI
b. f/u UC for organism and antibiotic sensitivity
c. daily CBC/CMP to assess for continued bleeding via H/H and electrolyte
abnormalities
d. Urology f/u in clinic
i. If UC negative, cystoscopy and retrograde CT urogram to assess urologic
cancer
ii. Kidney stone is very unlikely and does not need to be explored further.
However in cases with high suspicion of stones, the best imaging
modalities for stone detection is CTAP no contrast
e. GYN f/u in clinic
i. Women’s health primary care and assess risk of endometrial/vaginal
bleeding
2. Left lower extremity edema
a. Calf swelling >3 cm compared to the other leg, entire leg swollen, period of
immobility - Well’s Score = 3
b. r/o DVT with Doppler LLE U/S
3. Vertigo
a. Stable now. Meclizine PRN 25 mg oral tablet, 2 tabs orally 3 times a day
4. Hypertension
a. Continue with atenolol 50 mg po QD
b. Continue with NIfedipine 10 mg po QD

Discussion:
The workup for hematuria starts with a UA. A proper UA requires a clean catch, a technique that
can be difficult to achieve consistently. The presence of squamous cells in the UA indicates a
poor sample and possible contamination. UA will help confirm hematuria and tell us about the
potential etiology which will guide further workup. UA with leukocyte esterase, nitrites, and
WBCs increase suspicion for UTI and a urine culture is the next step. UC will confirm infection
and guide antimicrobial coverage. Our patient had hematuria so she cannot be classified as
asymptomatic bacteriuria. However in patients with asymptomatic bacteriuria, empiric treatment
is not recommended. The only groups that should be treated for asymptomatic bacteriuria are
pregnant women, those set to undergo urologic procedures, and those who recently had a renal
transplant.

In cases of hematuria that cannot be attributed to UTI, a urology outpatient appointment is

indicated in order to work up urologic cancers. Gross, painless hematuria is often associated with
cancer of the urogenital tract. The most common of the urogenital cancers is bladder cancer. Risk
factors for bladder cancer include smoking, environmental toxins and occupational toxins.
Evaluation of the urogenital tract for cancers include cystoscopy and CT urogram. Cystoscopy
allows visualization of the bladder walls to identify lesions. CT urogram allows visualization
upstream from the bladder to detect potential ureteral and renal cancers. However, hematuria that
can be associated to UTI does not need to be worked up for cancers.

Although unlikely in our patient, hematuria can also be caused by kidney stones. Kidney stones
are associated with flank pain, hematuria, nausea, and vomiting. Kidney stones can also lead to
infection since an impacted stone can cause retrograde bacterial travel throughout the urinary
tract. The best modality for detection of stones is non contrast CT. However, ultrasound has
shown to be a good modality in detecting stones while decreasing radiation to the patients. There
is evidence that US can be a good first line imaging tool for suspected stones. Based on the size
of the stone, clinical presentation of the patient, and hemodynamic status, different treatment
options are available. Stones that are greater than 6mm have a 1% chance of spontaneously
passing, stones that are 4-6mm have a 50% chance of passing spontaneously, stones that are
3mm have a 86% chance of passing spontaneously, and stones 2mm or less have a 97% chance
of passing spontaneously. Therefore, stones under 6mm can undergo a trial of hydration and
tamsulosin while stones over 6mm should undergo lithotripsy or lithotomy.

References:
Bono MJ, Reygaert WC. Urinary Tract Infection. StatPearls.
https://www.ncbi.nlm.nih.gov/books/NBK470195/. Published 2021. Accessed February 15,
2022.

Givler DN, Givler A. Asymptomatic Bacteriuria. StatPearls.

https://www.ncbi.nlm.nih.gov/books/NBK441848/. Published 2021. Accessed February 15,
2022.
Perazella MA, O’Leary MP. Etiology and evaluation of hematuria in adults. UpToDate.
https://www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults?
search=hematuria&source=search_result&selectedTitle=1~150&usage_type=default&display_ra
nk=1#H10. Published 2022. Accessed February 15, 2022.

Schubbe M, Takacs EB. Medical student curriculum: Kidney stones. Medical Student
Curriculum: Kidney Stones - American Urological Association.
https://www.auanet.org/education/auauniversity/for-medical-students/medical-students-
curriculum/medical-student-curriculum/kidney-stones. Published 2019. Accessed February 15,
2022.

Bindman RS, Aubin C, Bailitz J. Ultrasonography versus computed tomography for suspected
nephrolithiasis. The New England Journal of Medicine.
https://pubmed.ncbi.nlm.nih.gov/25229916/. Published September 18, 2014. Accessed February
15, 2022.