9/8/17 Intern Morning Report – Hematuria, Urinary clots, Hypercalcemia, Renal Cell Carcinoma

CC: Bloody urine

ID: This is a 56 yo M with history of hypertension and prior episodes of gross hematuria that presents with bloody urine for three days. In addition he has noticed clots in his urine, flank pain, constipation as well as decrease urine output. However, the patient denies dysuria, fevers, or weight loss. His exam demonstrates slight suprapubic pain but no other significant findings. Organomegaly was not appreciated but it was a difficult exam due to body habitus. Labs were significant for BUN/Cr: 26/1.65, Calcium 11, UA: large blood, >50 RBC/HPF with 100 protein and no RBC casts, and PTHrP 41. Given hypercalcemia secondary to elevated PTHrP and non-glomerular bleeding, suspicion for renal cell carcinoma is high. A CT urogram was pursued demonstrating necrotic right renal mass, involving the right renal vein and indeterminate involvement of the inferior vena cava.


Teaching Points

  1. Differentiate between glomerular and non-glomerular bleeding in hematuria cases

Glomerular Bleeding Findings

Non-Glomerular Bleeding Findings

·               Urinary acanthocytes

·               Urinary RBC casts

·               Proteinuria

·               Decrease renal function

·               Systemic symptoms

 

·               Urinary clots

·               Isomorphic RBCs

2. Perform a basic work up for Hypercalcemia:

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