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Paul Pitation is a 5 year old boy who has presented to the paediatric assessment unit with with his mother, due to problems with his eyes. His mother states that he is otherwise fit and well.

Please take a history from his mother and perform the relevant examination. You will then be asked to provide a summary of the case, present a differential diagnosis and discuss aspects of the case with the examiner.

You are the mother of Paul Pitation, a 5 year old boy. When he woke up this morning you noticed his eyes were really puffy and when he went for a wee he told you that his urine “looked weird”.

HPC: When you went to wake Paul up for school this morning, you noticed that his eyes were really puffy and you didn’t know why. He sometimes gets hayfever so you thought it might be that he had been rubbing his eyes in the night. It’s that time of year after all. He then got up and went for a wee which he told you looked really weird. You went and had a look and it looked really dark, like cola. This combined with the puffy eyes worried you because it seemed really unusual, so you brought him in. He has been under the weather for the past few days and hasn’t been as active as he would normally be. You have not noticed if he’s had a temperature. He hasn’t vomited or had any diarrhoea.

He has been going for a wee slightly less often for the past few days but he hasn’t complained of any pain on urinating. He has had no cough or coryzal symptoms, no headaches and no rashes. He has been eating and drinking as normal. If anything, you’ve had him drinking lots and lots. You gave him lots of flat diet cola to drink, because that’s what your mum used to give you when you were poorly! About 3 weeks ago, he had some weird crusty bits of skin around his mouth, which were a yellow-gold colour. You took him to the GP who gave you some antibiotic cream to put on it and it cleared up.

PMH: He was recently diagnosed with asthma for which he has a blue inhaler. He uses this once or twice a week when he plays football with his friends. You’re a bit worried that this might stop him doing exercise in the future, but for now he has been doing fine. He is otherwise fit and well.

He is up to date on all of his vaccinations.

BH: Paul was born at 38 weeks gestation and you had a forceps delivery because he was taking too long to come out. He was 7lb 9oz and did not need any extra care after birth. Apart from one occasion where you had to come into hospital for fluids because your morning sickness was so bad, there were no complications in the pregnancy.

He is growing well and hitting all his developmental milestones.

DH: He takes no regular medication apart from his blue inhaler and has no allergies.

FH: There is no significant family history of any medical problem. Nobody else in the family has been unwell recently.

SH: Paul lives at home with you, his father (your husband) and his little sister who is 3 years old. You also have a chocolate labrador called Stanley. You work as a teaching assistant and your husband is a gardener. Neither of you smoke. Paul started school last year and is doing really well. He has made lots of friends and loves playing football – he’s always coming home covered in mud!

ICE: You have absolutely no idea what could be going on. The puffy eyes and dark urine seem very random and you’re worried it could be something quite serious. You would like to know what is going on and get it fixed.

Please observe the student take a history from this patient. Ideally they should perform a GI examination. Ask them to present their findings and list their differentials, which should include a renal disorder secondary to recent infection. An ideal differential diagnosis would sound something like:

“My primary differential diagnosis would be a renal cause: more specifically glomerulonephritis. This is due to the peri-orbital oedema an dark-looking urine. Given the recent history of infection, a post-streptococcus Glomerulonephritis would be the most likely cause. I would also want to consider nephrotic syndrome, given the oedema, however the urine would be less likely to be dark in this case.”

Topics for discussion may include: • What might you expect to find when this patient’s basic obs are taken? • What other investigations would you like to do to confirm the diagnosis? • How would you manage this patient? • What long term follow up might this patient require? • Tell me about the different types of glomerulonephritis. • What dermatological infection did this patient experience on his face recently?