A 14-year-old boy is brought to the pediatrician by his mother because he has had a fever with shaking chills for the past day. On physical examination, he has a temperature of 39.6 C and has mild right costovertebral angle tenderness.

Questions:

1. How do you explain the appearance of the urine? How do you relate this to other findings?

The urine is cloudy (turbid). This could result from increased numbers of suspended particles (cells or cell fragments, casts, crystals, or amorphous semicrystalline material). The presence of the blood suggests that RBC's are present. The postive leukocyte esterase suggests that WBC's are present.

2. What is the significance of the finding on physical examination?

The CVA tenderness suggests inflammation in the kidney.

3. Is there a relation between the color of the urine and the diagnosis?

The color is not obviously red.

4. What findings on microscopic urinalysis would be of help?

Finding WBC's, particularly WBC casts, would suggest inflammation, particularly of the kidney.

5. What is the suspected diagnosis?

Acute pyelonephritis, probably as a consequence of an ascending urinary tract infection.

6. What else should you do?

Urine culture. Later, one would do an intravenous pyelogram (IVP) and voiding cystourethrogram (VCUG)--very useful in a boy with a urinary tract infection (UTI), which is not common. He may have urinary tract abnormalities.