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PE20.1-9 | Genito-Urinary System — Assignment

CLINICAL SCENARIO

Students will work up a structured clinical case of a school-age child presenting with haematuria, oedema, and altered urine output — a presentation that spans UTI, glomerulonephritis, nephrotic syndrome, and HUS. The writeup demands interpretation of urine examination findings, differential reasoning between nephritic and nephrotic syndromes, integration of KUB and ultrasound findings, and a evidence-based management plan. This assignment prepares students to approach renal presentations systematically in an Indian paediatric outpatient and emergency setting.

Instructions

Read the case vignette below carefully.
Complete each section of the scaffolding in the order given.
Use Ghai Essential Pediatrics, Nelson Textbook of Pediatrics, and IAP guidelines as your references — cite them explicitly.
Base all drug doses on weight (mg/kg); do not use adult fixed doses.
Submit a typed document of 900–1300 words (excluding the urine microscopy interpretation table).
After submission, review one peer's assignment using the rubric criteria provided.

Case vignette: Rahul, an 8-year-old boy from a peri-urban area, presents to the paediatric OPD with periorbital puffiness for 4 days, cola-coloured urine for 2 days, and reduced urine output. His mother reports he had a sore throat with fever 12 days ago treated with paracetamol only. On examination: BP 145/95 mmHg, mild periorbital oedema, no ascites, heart rate 94/min, temperature 37.2°C, and bilateral 1+ pitting pedal oedema. Urine dipstick: protein 2+, blood 3+, leucocyte esterase negative. Urine microscopy: 40 RBCs/HPF (dysmorphic), RBC casts present, no WBC casts. Serum creatinine 1.2 mg/dL, albumin 3.4 g/dL, C3 low, ASO titre 640 IU/mL. Renal ultrasound: mildly enlarged, echogenic kidneys bilaterally.

Length: 900–1300 words (excluding microscopy interpretation table)

What to Submit

1. Differential Diagnosis (with Reasoning)

Guidance: List your top 3 differential diagnoses for this presentation. For each, state which clinical/lab features support it and which argue against it. Apply the nephritic vs nephrotic framework explicitly: state the defining features of each syndrome and classify Rahul's presentation accordingly.

2. Most Likely Diagnosis and Justification

Guidance: State your single most likely diagnosis and justify it using: (a) the latent period after pharyngitis, (b) the complement pattern (low C3), (c) the urine microscopy findings (type and significance of RBC casts), and (d) the serology. Explain why the low C3 supports this diagnosis and what its expected trajectory is over the next 6–8 weeks.

3. Urine Examination Interpretation

Guidance: Interpret Rahul's urine examination findings systematically: (a) dipstick — explain what protein 2+ and blood 3+ signify quantitatively; (b) microscopy — state what dysmorphic RBCs indicate (glomerular vs non-glomerular haematuria) and explain the pathological significance of RBC casts; (c) explain why leucocyte esterase is negative in this case.

4. Immediate Management Plan

Guidance: Write a prioritised management plan for the first 24–72 hours covering: (a) fluid restriction rationale and target (state Holliday-Segar maintenance as baseline reference — 100/50/20 mL/kg/day — and your adjustment), (b) antihypertensive choice and dose (mg/kg), (c) dietary sodium restriction, (d) monitoring parameters (urine output, BP, serum creatinine, electrolytes, weight), and (e) indications for urgent dialysis. Do not prescribe antibiotics unless you have a specific justification.

5. Red-Flag Monitoring and Referral Criteria

Guidance: List the specific clinical and biochemical parameters that would prompt you to escalate this child to a paediatric nephrologist. Include: criteria for renal biopsy, signs of hypertensive urgency/encephalopathy, and the finding that would make you reconsider the diagnosis of APSGN (hint: think about C3 trajectory).

6. Long-Term Follow-Up Plan

Guidance: Describe the recommended follow-up for a child with APSGN over the next 12 months: monitoring intervals, parameters to check (C3, creatinine, BP, urinalysis), and the expected resolution timeline. State the prognosis of APSGN in children vs adults.

Grading Rubric — Genito-Urinary System Case Writeup Rubric

Criterion	Points	Full-marks descriptor
Differential diagnosis framework and nephritic/nephrotic distinction	20 pts	Three well-reasoned differentials with supporting and refuting evidence for each; nephritic and nephrotic syndromes correctly defined and Rahul's case accurately classified as nephritic.
Accurate diagnosis of APSGN with evidence-based justification (latent period, C3, RBC casts, serology)	20 pts	APSGN correctly identified; all four supporting elements (1–2 week latent period, low C3 with 6–8 week normalisation timeline, RBC casts signifying glomerular pathology, elevated ASO titre) correctly described and integrated.
Urine examination interpretation (dipstick, microscopy, cast pathophysiology)	20 pts	Protein 2+ quantified (approximately 100 mg/dL); blood 3+ interpreted as significant haematuria; dysmorphic RBCs correctly identified as marker of glomerular origin; RBC cast formation (Tamm-Horsfall protein + glomerular RBCs) and diagnostic significance correctly explained; negative leucocyte esterase correctly linked to absence of bacterial infection.
Management plan — fluid, antihypertensive, monitoring, and dialysis criteria (weight-based dosing throughout)	20 pts	Fluid restriction quantified with Holliday-Segar baseline stated (100/50/20 mL/kg/day) and restriction appropriately justified; antihypertensive choice and dose in mg/kg stated correctly; sodium restriction mentioned; monitoring parameters (hourly urine output, daily weight, 6-hourly BP, creatinine/electrolytes) comprehensive; dialysis indications (hyperkalaemia >6.5 mEq/L, fluid overload, hypertensive encephalopathy, severe uraemia) correctly listed.
Red-flag criteria, referral triggers, and long-term follow-up plan	20 pts	Red flags (hypertensive encephalopathy, AKI not resolving, C3 still low at 8 weeks, persistent nephrotic-range proteinuria) correctly listed; biopsy criteria explicit; long-term follow-up plan with 3-monthly BP/urinalysis × 12 months and expected resolution timeline (haematuria resolves 1–6 months, proteinuria resolves months to 1 year, C3 by 6–8 weeks) stated; prognosis comparison (children = excellent, adults = poorer).

PEER REVIEW

Using the rubric criteria above, evaluate your peer's assignment on each of the 5 criteria (20 points each). For each criterion: (a) assign a score from the rating descriptors, (b) write 2–3 sentences explaining your score, and (c) identify ONE specific factual strength and ONE area for improvement. Calculate a total score out of 100 and write a 3–4 sentence overall comment on the quality of clinical reasoning demonstrated.