| | DARK URINE
Door way information about patient
The patient is a 20-year-old man who comes to the clinic due to dark urine for 5 days .
Vital signs
. Temperature : 36.7’C (98F)
. Blood pressure : 122/80 mmHg
. Pulse : 74 /min
. Respirations : 14/min
Approach to the patient
Patients may report unusual or undifferentiated symptoms that could be due to disease in multiple systems . In some cases , this may represents a -cardinal manifestation- of an uncommon condition (eg, the “ target shaped “ rash of Lyme disease). Alternately , unusual symptoms may be an -atypical manifestation- of a common disorder (eg, systemic lupus erythematous presenting as migratory mononeuropathy).
Dark urine can represent either an unusually concentrated urine , gematria , or an -abnormal pigment- in the urine. Abnormal urine color is usually due to disorders of the renourinary tract, hepatobiliary system, blood/hematologicc system , or musculoskeletal system. If the patient otherwise feels well, abnormal urine color is usually benign.
Differential diagnosis
The color of the urine can guide the differential diagnosis:
. -Red- ; Blood , food pigments (eg, beets , rhubarb) , medications (eg, phenazopyrudine, rifampin), porphyrins.
. -Blue/green- : Food dyes , medications (eg, indomethacin, amitriptyline) , Pseudomonas urinary tract infection.
. -Brown- : Medications (eg, ,metronidazole, senna), liver/kidney disease, myoglobin/rhabdomyolysis
. -Orange- : Hepatobiliary disease, dehydration
-Hematuria- can be categorized by the patten though urination . Blood at the start of voiding that clears is usually from a urethral source . Blood at the end of voiding suggests a bladder or prostate source .Visible blood thought voiding may represent an upper tract (kidney and collecting system) source.
-Biliary obstruction- May cause dark-yellow/orange wurine with jaundice , pale stool m and right upper quadrant pain . Hematuria in a patient with a history of heavy smoking is a common presentation of -bladder cancaer- . Dark urine following a crush injury or extreme physical exertion suggests -rhabdomyolysis- . In addition , -hemolysis- may case dark urine with fatigue , jaundice m and back or abdominal pain .
HISTORY AND PHYSICAL EXAMINATION
In addition to the standard general medical history and physical examination, the following sections include the most common items that should be included in the evaluation of a patient with dark urine.
History
History of resent illness
. What color is your urine?
. When did you first noticed the dark urine?
. Is there blood in the urine?
. Have you noticed a change in the quantity of urine?
. Do you have pain with urination?
. Have you had abdominal or back pain?
. Have you had fever or chills?
. Do you have nausea , vomiting , or diarrhea?
. Have you eaten anything(eg,berries , collared food , beets) that could cause this color?
. Have you had recent injuries or heavy exercise?
. Have you had rennet infections , such as a sore throat?
. Have you had previous urinary or kidney problems?
Psst medical history
. Have you had a similar problem before?
. Have you been diagnosed with any otters medical conditions(eg,diabetes, hypertension)?
Medical /allergies
. Do you take any medications?
Social history
. What kind of work do you do?
. Do you smoke ? At what age did you start & how much do you smoke?
. Do you drink alcohol ? How much & how often?
. Have you used recreational drugs?
Physical examination
General
. Observe level of alertness & hydration
HEENT
. Examine the oropharynx.
. Examine the sclera.
Skin
. Observer pallor or jaundice
. Inspect for signs of liver disease (eg,spider angiomata, planar erythema)
Abdomen
. Auscultate bowel sounds.
. Examine the liver & solemn for enlargement or tenderness
. Examine for suprapublic & costovertebral angle tenderness.
Closing the encounter
In the warp-up discussion , the first step is to discuss the likely diagnosis along with an assessment of the diagnostic uncertainly . If a patient has pathognomonic findings for a particular disease , you should explain the significance of them, if you are uncertain about the diagnosis , say so clear, but pressure the patient that you will work with them to identify the cause.
Regarding diagnostic tests, If invasive studies are necessary (eg, cystoscopy in an elderly smoker with hematuria), explain the rational for the test. Allow time for questions , and assess the patient’s readiness to undergo the studies you recommend.
Diagnostic workup
Patients with an abnormal urine color should have a urinalysis with microscopic analysis of urinary sediment (i.e., for casts , crystals , etc) . Note that patients with myoglobinuria amy have a positive test for hemoglobin on chemical(‘ dipstick”) urinalysis without red blood cells microscopic analysis.
Other studies may include:
. Electrolytes , blood urea nitrogen, creatinine
. Liver function tests (eg, direct and indirect bilirubin)
. Urine culture
. Complete blood count( and peripheral smear , reticulocyte count)
. Muscle enzymes (eg, creatinine kinase, aspartate aminotransferase[AST])
. CT urogram (for identify kidney stones)
. Liver /biliary CT scan , ultrasound
. Cystoscopy
{Patient with hematuria should have evaluation of both the upper and lower urinary tract. Typical studies include CT urogram and cystoscopy , but the specific evaluation may be individualized.
If hemolytic anemia is suspected , start with a complete blood count , reticulocyte count , and peripheral smear . Supportive findings include elevated lactate dehydrogenase, low haptoglobin, and elevated unconjugated bilirubin , These should be performed before specific testing (eg, hemoglobin electrophoresis , glucose-6-phosphatase dehydrogenase , osmotic fragility)
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2018/06/05 10:44pm 
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