Pee Too Much
A 13-year-old girl presents to her primary care physician for increased frequency of urinating, thirst, and urinating at night. She was in a car accident about a month ago, where she had head trauma. Since then, she reports that she has noticed this increased frequency of urination. At that time, head imaging had been normal. She has very dilute urine. She is exhibiting symptoms of?
Answer: Diabetes insipidus (likely central 2/2 head injury)
Diabetes insipidus is a condition in which the kidneys are unable to conserve water, often because there is insufficient antidiuretic hormone (central) or the kidneys are unable to respond to ADH (nephrogenic). Although diabetes mellitus may present with similar symptoms, the disorders are different. Diabetes insipidus does not involve hyperglycemia.
9 year old Brattney McStubborn gagged on the second bite of hotdog that her parents made her eat which caused her to vomit. Now she is refusing to eat or drink anything. Her parents are determined to handle this on their own, but then Brattney has several episodes of watery diarrhea. Brattney is taken to the hospital for evaluation. In addition to being found to have food poisoning from an undercooked hotdog, her labs show that she has an acute kidney injury 2/2 dehydration. A viscero-somatic reflex to what region is expected in this patient in regards to her AKI?
A. T1-T4
B. T5-T9
C. T10-T11
D. T12-L2
E. L3-L5
Answer: C. T10-T11. Kidneys
According to facts, a viscero-somatic reflex occurs when localized visceral stimuli produce patterns of reflex response in segmentally related somatic structures. T1-T4 is associated with head and neck. T5-T9 is upper GI. T12-L2 is prostate (and some overlap with other organs that does not include the kidneys). L3-L5 is right out.
6yo Annie has had 6 UTIs in her lifetime. Her mother cannot explain why, as previous imaging with her prior PCP was all negative and Annie's mother has never had a UTI, it does not run in their family. She is confused and concerned. What should you ask questions about?
Sexual abuse
Always need to r/o when children have multiple UTIs
At what age should children start toilet training?
More than two-thirds of U.S. children achieve the physiologic, cognitive, and emotional development necessary for toilet training by 18 to 30 months of age.
Grade C recommendation
Adults may have autosomal _____ polycystic kidney disease and infants may have autosomal _____ polycystic kidney disease.
A: dominant, dominant
B: dominant, recessive
C: recessive, recessive
D: recessive, dominant
B: Adults - dominant, infants - recessive
A 14 year old female presents to clinic complaining of vaginal itching. She is not sexually active and denies sexual assault. The patient is annoyed that she is constantly having to urinate. She says she is urinating all the time because she is always thirsty. The patient seems more worried about her constant eating because she is worried about gaining weight. The patient’s UA is negative for infection. Wet mount confirms a diagnosis of vaginal candidiasis. What is the likely cause of this pt’s symptoms and yeast infection?
Answer: Type 1 diabetes. The signs and symptoms that suggest type 1 diabetes include excessive thirst, hunger, urination, weight loss, fatigue, irritability, blurred vision, and infection with candida albicans (also known as yeast infections).
14 year old Dora presents to clinic with her mother complaining of urinary symptoms for the past three weeks. She says it started with some burning with urination and then she started having suprapubic pain associated with an urge to empty her bladder. She decided to walk it off while doing some exploring with her cousin. Can you say “mistake”? She reluctantly presented to clinic today because she is now having left flank pain and blood in her urine. She is evasive in regards to her sexual history and when you ask permission to get a vaginal swab she replies “swabbers no swabbing!”. UA is positive for infection and when you percuss the left flank she yells in pain and takes a swing at you.
Where might you expect to find a posterior gangliform contraction that is smooth, firm, and approximately 2-3mm in diameter? (if such a thing does exist) Select the two correct answers.
A. T10-11 intertransverse space
B. T11-T12 intertransverse space
C. T12-L1 intertransverse space
D. L1-L2 intertransverse space
E. L2-L3 intertransverse space
Answer: C and D. Posterior Chapman points for the kidneys are between the spinous and transverse processes of T12 and L1. Posterior Chapman point for the bladder are between the spinous and transverse processes of L1-L2. 11th intervertebral space is the adrenals and 10th intervertebral space is included in the Chapman points for the small intestine. Theoretically a Chapman’s point represents the somatic manifestation of a visceral dysfunction. They are used more for diagnostic purposes than for treatment if they are used at all.
8yo Jo Anne comes in with dysuria and genital pruritis. You get a UA which comes back positive for UTI. On culture, she grows a bacteria that is known to have an ammonia-like scent. Name the bug.
Proteus mirabilis
If a child is not day time potty trained by what age should undiagnosed physical or cognitive deficit be considered?
According to the American Academy of pediatrics children who are not at least daytime potty trained by age 4 should be evaluated for underlying cognitive or physical cause (ie Autism, cerebral palsy, neurologic problem affecting sphincter or bowel control.
4yo Jamie was dx w/ a fungal UTI after c/o typical UTI sx. List two risk factors for fungal UTIs.
-indwelling urinary catheter
-immunosuppression
-long-term use of broad-spectrum abx
14 year old Dora presents to clinic with her mother complaining of urinary symptoms for the past three weeks. She says it started with some burning with urination and then she started having suprapubic pain associated with an urge to empty her bladder. She decided to walk it off while doing some exploring with her cousin. Can you say “mistake”? She reluctantly presented to clinic today because she is now having left flank pain and blood in her urine. She is evasive in regards to her sexual history and when you ask permission to get a vaginal swab she replies “swabbers no swabbing!”. UA is positive for infection and when you percuss the left flank she yells in pain and takes a swing at you.
What two places might you expect to find an anterior gangliform contraction that is smooth, firm, and approximately 2-3mm in diameter? (if such a thing does exist)
Answer: Anterior Chapman points for kidneys are 1” superior and 1” lateral to the umbilicus. Anterior Chapman point for the bladder is the periumbilical region. Theoretically a Chapman’s point represents the somatic manifestation of a visceral dysfunction. They are used more for diagnostic purposes than for treatment if they are used at all.
10yo Johnny presents for a routine physical and his father presses for a UA because "his urine smells so strong - he needs to drink more water." Child is asymptomatic. You run a UA which shows + bacteria and + yeast. However, urine culture returns with candida only. What is the most appropriate next step?
Watch and wait. Do not treat asx candiduria unless:
-Neutropenic pt
-VLBW <1500g) infant
-Urologic procedure in near future (tx w/ Fluconazole or Amphotericin B)
What percentage of chronic encopresis is functional (meaning no underlying medical or organic cause)?
A) 10%
B) 25%
C) 50%
D) 75%.
E) 90%.
The correct answer is "E."
Ninety percent of chronic encopresis is functional.
Which IgA-mediated vasculitis can affect children's kidneys?
HSP (Henoch-Schönlein purpura)
-primarily between the ages of 3 and 15 years
•Palpable purpura without thrombocytopenia and coagulopathy
•Arthralgia/arthritis
•Abdominal pain
•Renal disease
Your patient is a post-surgical kiddo that has not voided since surgery. You have already treated the bladder with OMT. What OMT technique directed at what level/area can be used to normalize (decrease) sympathetic activity to the kidneys/upper ureters. (There are two correct answers)
Answer: Rib raising at T10-11 and Superior mesenteric release. Thoracic sympathetic ganglia lie anterior to their corresponding rib. It is believed that that gentle anterior pressure on the ganglia with produce a short lived increase in sympathetic tone followed by long lasting sympathetic inhibition. Midline abdominal pressure over the superior mesenteric ganglia will reduce hypersympathetic activity. Pressure is applied until a facial release is palpable.
Prevalence of UTI is greatest in a child who fits in all of these 3 groups:
-Age
-Gender
-Misc
_________________
-Bonus (not really a bonus): race
-Under 3 mos
-Male
-Uncircumcised
-White
While studies show that no method of toilet training is superior only this method is endorsed by both the American Academy of Pediatrics and the Canadian Pediatric Society?
The Child-Oriented Approach or Brazelton Method of toilet training. Grade C recommendation.
Note AAFP has no specific recommendation and instead encourages family to choose what method is right for them.
2.5yo Freddie was in for a wellness exam when his abdomen revealed mass(es) in the flank region(s). His mother noted she just began seeing blood in the toilet after Freddie potty trains.
What is the most common renal malignancy of children 2-4yo? Is it unilateral or bilateral?
Wilms tumor (nephroblastoma)
Unilateral
Contains embryonic glomerular structures. Large unilateral flank mass and hematuria in 2-4year olds. Gene WT1 or WT2 on chromosome 11.
WAGR complex= Wilms tumor + Aniridia + GU malformations + "Retardation"
A G1 now P1 15yo female presents to clinic with her two week old son Clover for his first well visit. Mother did not have any prenatal care as she does not trust traditional medicine and believes that she knows what is best for her body and for Clover. She reluctantly brought Clover to the clinic today after her mom made her do it because Clover has had some blood in his urine and is crying constantly and is very fussy. Upon questioning he is eating well and stooling appropriately, but only has 2-3 urines per day. Physical exam reveals a left sided abdominal mass. UA is positive for infection and US reveals left hydronephrosis. Ultimately the diagnosis of ureteropelvic junction obstruction is made. Obstruction of the ureter with resulting hydronephrosis and acute pyelonephritis will have the least effect on which of the following structures?
A. Vagus
B. Pelvic Splanchnic
C. Sympathetic chain ganglia of T12-L1
D. Sympathetic chain ganglia of T8-T9
E. Sympathetic chain ganglia of T10-T11
Answer: D, Sympathetic chain ganglia of T8-T9 are related to sympathetic innervation of parts the GI tract and do not involve components of the KUB.
Vagus nerve (CN X) is involved in Parasympathetic innervation to Kidney and upper ureter. Pelvic Splanchnic nerve may be effected to a lesser degree depending on where ureter obstruction occurs as it is involved with parasympathetic innervation to the lower ureter and bladder. Sympathetic chain ganglia of T12-L1 are involved with sympathetic innervation of the lower ureter. Sympathetic chain ganglia of T10-T11 are involved with sympathetic innervation of Kidneys and upper ureters.
5yo Stephanie is diagnosed with UTI after c/o bladder fullness, incomplete emptying, and dysuria. 3+ LE on UA. E.coli is the MC organism responsible for UTIs. Name two additional gram positive organisms and two additional gram negative organisms known to cause UTIs (be specific with your gram positive answers.)
+ : Staph saprophyticus, Enterococcus, Staph aureus
- : Klebsiella, Proteus, Enterobacter, Citrobacter
Name three signs Children are ready to initiate toilet training?
Asks to wear “big kid” underwear
Can put on and take off clothes (generally achieved by 30 months of age)
Can walk to and from the toilet (generally achieved by 15 months of age)
Facial expressions, postures, words, or behaviors that indicate the child is about to urinate or defecate: grimacing, grunting, or squatting when needing to defecate; holding the groin, tugging at diaper, or crossing legs when needing to urinate (75% achieve by 26 to 29 months of age)
Imitates parental behavior
Regular, predictable bowel movements and nighttime bowel control
Shows discomfort with soiled diapers and wants to be changed
Shows interest in using the toilet; demonstrates desire to learn to control bladder and bowel function (75% achieve by 24 to 26 months of age)
Stable posture while sitting on the toilet
Stays dry for two hours at a time or during naps (75% achieve by 24 to 26 months of age)
Sufficient expressive language skills to communicate the need to void (with words or agreed-upon gestures)
Name 3 components of Potter's syndrome.
Pulmonary hypoplasia
Oligohydramnios (trigger)
Twisted face
Twisted skin
Extremity defects
Renal failure (in utero)
Compression of developing fetus 2/2 oligohydramnios, results in abnormalities listed above. Lack of amniotic fluid aspiration in utero leads to pulmonary hypoplasia and can cause death.