Hematuria/Proteinuria Evaluation Note (Pediatric)

Date/Time: [Encounter date and time]

Patient Name: [Full name]

DOB: [Date of birth]

Age: [Age in years and months]

Encounter Setting: [outpatient clinic / consult / ED follow-up]

Referral Source/Consult Question: [Referring clinician and specific question] (Only include if applicable)

Historian: [patient / parent-guardian / other] (Note reliability if limited)

Chief Concern

[Single-sentence summary of reason for evaluation] (State succinctly the primary concern related to hematuria and/or proteinuria)

Brief Case Summary

[2–4 sentence synopsis including key finding (hematuria type, proteinuria presence/degree), BP status with interpretation, kidney function status, symptom pattern, and initial risk tier impression (low-risk isolated finding vs concerning for parenchymal disease)] (Do not overstate certainty if data are incomplete)

History of Present Illness

(Open with the chief concern, then narratively organize details. Include only information explicitly obtained this encounter or from reviewed records.)

Hematuria characterization: [Microscopic vs gross; onset and duration; urine color (pink/red vs brown/tea/cola); clots present/absent; timing during void if known; associated urinary symptoms (dysuria, frequency, urgency); pain location; fever/systemic symptoms; triggers (vigorous exercise, recent URI, dehydration); bleeding confounders (menstruation, perineal irritation, trauma, instrumentation); prior UA results with dates]

Proteinuria characterization: [Detection context (screening vs symptomatic); persistence (number of abnormal specimens with dates); prior quantification (UPCR/UACR with dates); nephrotic features (edema, rapid weight gain, decreased urine output, foamy urine); potential transient causes (fever, exercise, dehydration) and timing relative to testing]

Nephritic/glomerular syndrome screen: [New/worsening hypertension symptoms, edema location, oliguria, dark urine, rash, arthralgias, abdominal pain, recent pharyngitis or skin infection, oral ulcers, photosensitivity] (Include when hematuria confirmed or protein ≥1+)

Exposures and context: [Recent antibiotics, NSAIDs, anticoagulants; recent infections; contact sports/trauma]

Records reviewed: [Summary of UA trend, UPCR/UACR, creatinine, BP with dates and ranges] (If key information is unknown or unavailable, document as unknown and state plan to clarify/obtain records)

Review of Systems

• Constitutional: [Fever, weight change, fatigue]
• Skin: [Rash, purpura, petechiae]
• HEENT: [Recent pharyngitis, hearing changes] (Include hearing screen for hereditary nephritis if relevant)
• Respiratory: [Hemoptysis, dyspnea] (Include if vasculitis concern)
• GI: [Abdominal pain, diarrhea] (Consider HUS/IgA vasculitis context)
• MSK: [Arthralgias, joint swelling]
• GU: [Dysuria, urgency, frequency, flank pain, menstrual history if applicable]

Past History

• Prior UTIs/pyelonephritis: [Details]
• Voiding dysfunction/constipation: [Details]
• Known kidney/urologic anomalies: [Details including CAKUT/prenatal findings if relevant]
• Nephrolithiasis or hypercalciuria: [History and workup if any]
• Sickle cell disease/trait: [Status] (Only include if relevant to population)
• Chronic illnesses impacting differential: [Details] (Only include if relevant)
• Medications: [Current medications with recent changes; note nephrotoxic agents]
• Allergies: [Allergen and reaction type]

Family History (high-yield): [Hematuria/proteinuria in relatives; CKD/ESKD/transplant; hearing loss or ocular findings; kidney stones/hypercalciuria; autoimmune disease]

Social History: [Hydration patterns; sports intensity; diet patterns relevant to stone risk] (Only include relevant details)

Physical Examination

• Vitals: [Temp, HR, RR, SpO2]
• Growth: [Height, weight, BMI or weight-for-length]
• Blood Pressure: [BP with cuff size and site] (For children <13 years, include percentile-based interpretation; for ≥13 years, include absolute BP and category. If BP not obtained, document reason and plan to obtain promptly.)
• General: [Appearance, distress level, hydration status]
• HEENT: [Periorbital edema, oropharynx findings]
• Cardiovascular: [Rate/rhythm, murmurs, signs of fluid overload]
• Pulmonary: [Work of breathing, breath sounds] (Note signs of fluid overload if present)
• Abdomen: [Tenderness, CVA tenderness, palpable masses]
• Skin: [Purpura, petechiae, edema location and severity]
• MSK: [Joint swelling/tenderness]
• GU (external): [Findings] (Only include if examined for trauma/irritation/bleeding source uncertainty)

Objective Data

Urine Studies

• Specimen metadata: [Collection method: clean-catch midstream / catheter / bag; date/time; first-morning: yes / no; menstruation/contamination risk: present / absent; urine appearance if gross hematuria: color, clarity, clots] Status: [Reviewed / Ordered / Pending] (Required when interpreting UA)
• Urinalysis dipstick: [Specific gravity, pH, blood, protein grade, leukocyte esterase, nitrite, glucose/ketones if relevant] Status: [Reviewed / Ordered / Pending] (Note if dipstick and microscopy diverge; consider myoglobinuria/hemoglobinuria if heme-positive with few/no RBCs)
• Urine microscopy: [RBCs/hpf; RBC morphology: isomorphic / dysmorphic; acanthocytes %; casts (RBC/WBC/granular/hyaline); WBCs/hpf; bacteria/yeast; crystals; epithelial cells] Interpretation: [Active urinary sediment / bland sediment; glomerular vs nonglomerular source assessment] Status: [Reviewed / Ordered / Pending] (State "findings suggest glomerular source" only if dysmorphic RBCs, acanthocytes ≥5%, or RBC casts present. If not available, document limitation and plan to obtain.)
• Protein quantification: [Method: first-morning UPCR / UACR / 24-hour collection; result with date] Status: [Reviewed / Ordered / Pending] (Interpret using age-appropriate normals: UPCR normal <0.2 mg/mg in older children, <0.5 mg/mg in younger children; nephrotic-range ≥2 g/g. If orthostatic evaluation performed, document first-morning vs daytime comparison. If only dipstick available, note limitation and plan to quantify.)
• Additional urine testing: [Urine culture, urine calcium/creatinine ratio, other] Status: [Reviewed / Ordered / Pending] (Only include if indicated)

Blood Studies

• Kidney function: [BMP/CMP including creatinine and bicarbonate; baseline if known] Status: [Reviewed / Ordered / Pending]
• Hematology: [CBC] Status: [Reviewed / Ordered / Pending]
• Complement: [C3, C4] Status: [Reviewed / Ordered / Pending] (When GN suspected)
• Post-infectious markers: [ASO, anti-DNase B] Status: [Reviewed / Ordered / Pending] (When relevant)
• Autoimmune/vasculitis serologies: [ANA, dsDNA, ANCA, anti-GBM] Status: [Reviewed / Ordered / Pending] (Only if clinically indicated)
• Nephrotic evaluation: [Serum albumin, lipid panel] Status: [Reviewed / Ordered / Pending] (If nephrotic syndrome suspected)

Imaging

• Study: [Modality and date] Indication: [Clinical question] Findings: [Key findings] Status: [Reviewed / Ordered / Pending] (Include prior imaging reviewed if applicable)

Assessment

[Concise synthesis addressing: (1) Syndrome pattern (isolated microscopic hematuria / gross hematuria / isolated proteinuria / combined hematuria+proteinuria / nephritic picture / nephrotic picture); (2) Evidence of kidney parenchymal disease risk (hypertension, impaired kidney function, active sediment, significant proteinuria); (3) Immediate risk tier and rationale] (Explicitly state uncertainty if microscopy or quantification is missing)

Differential Diagnosis

Top considerations:

• [Diagnosis 1]: [Supporting features; features arguing against; discriminating tests]
• [Diagnosis 2]: [Supporting features; features arguing against; discriminating tests]
• [Diagnosis 3]: [Supporting features; features arguing against; discriminating tests]

(Include 3–5 diagnoses organized by presentation pattern and risk stratification)

Hematuria by source:

• Glomerular: [Post-infectious GN, IgA nephropathy/IgA vasculitis nephritis, lupus nephritis, Alport/thin basement membrane disease, others]
• Nonglomerular upper tract: [Hypercalciuria/nephrolithiasis, structural anomalies, cystic disease, trauma]
• Lower tract: [UTI/cystitis, urethritis, instrumentation]
• Mimics: [Myoglobinuria/hemoglobinuria, menstrual contamination, dietary/medication urine discoloration]

Proteinuria categories:

• Benign/transient: [Fever, exercise, dehydration, orthostatic proteinuria]
• Glomerular: [Minimal change disease, FSGS, IgA-related, lupus, post-infectious, hereditary nephritis]
• Tubulointerstitial: [Drug-related interstitial nephritis, reflux nephropathy]

Plan

• Problem 1 – Hematuria:
  • Gross hematuria with dysuria/pyuria: [Urine culture; imaging consideration; infection treatment if confirmed; reassessment plan]
  • Gross hematuria without pain: [Microscopy; BP; kidney function; imaging for structural causes]
  • Microscopic hematuria (isolated): [Repeat UA with microscopy using proper collection; protein quantification; urine Ca/Cr ratio if stone risk; trending plan]
  • Hematuria with proteinuria, hypertension, impaired kidney function, or active sediment: [Urgent serologic workup; nephrology involvement with rationale and timing]
  (Branch by presentation; include timelines and contingency plans)
• Problem 2 – Proteinuria:
  • [Confirm persistence with repeat first-morning UPCR/UACR and UA with microscopy]
  • [If orthostatic pattern suspected: compare first-morning vs daytime quantification] (Especially relevant for adolescents)
  • [If nephrotic-range suspected: serum albumin, kidney function, BP and edema assessment, nephrology referral]
  • [If benign/transient likely: reassurance and repeat testing interval]
• Additional problems: [Hypertension management; kidney dysfunction management; nephrolithiasis/stone risk mitigation; voiding dysfunction; menstrual contamination counseling] (Only include applicable problems)
• Follow-up testing/monitoring: [Specific tests, timing, and responsible party]

Follow-up and Escalation Triggers

Planned follow-up: [Interval based on risk tier; parameters to recheck (UA with microscopy, UPCR/UACR, BP, creatinine as indicated)]

Immediate/ED evaluation triggers:

• Gross hematuria with clots and urinary retention
• Hematuria after significant trauma
• Oliguria/anuria or rapidly rising creatinine
• Severe edema or respiratory distress
• Severe or markedly elevated blood pressure
• Systemic illness suggesting HUS or vasculitis (bloody diarrhea with anemia/thrombocytopenia concern, hemoptysis)

Urgent nephrology referral triggers:

• Hematuria plus proteinuria beyond benign thresholds
• Active urinary sediment (RBC casts or significant dysmorphic RBCs/acanthocytes)
• Persistent microhematuria beyond observation window
• Hypertension or impaired kidney function
• Recurrent gross hematuria without clear benign cause
• Family history suggestive of hereditary nephritis

Urology referral triggers:

• Structural lesions on imaging
• Hydronephrosis/obstruction
• Suspected lower-tract bleeding requiring procedural evaluation
• Stones requiring intervention

Patient and Family Education

• [Explanation of current findings, uncertainty, and next steps]
• [Urine collection instructions: first-morning timing, clean-catch technique, avoid vigorous exercise before repeat UA if relevant]
• [Hydration guidance and dietary considerations if stone risk]
• [Medication avoidance (e.g., NSAIDs if kidney disease suspected) and safe alternatives]
• [Return precautions mirroring escalation triggers above]
• [Communication plan for pending results and contact method]

(Use direct patient/family quotes selectively for salient observations)

Orders and Care Coordination

• Labs ordered: [List with timing]
• Imaging ordered: [List with clinical question and timing]
• Referrals: [Nephrology / Urology / Other with urgency and reason]
• Communication: [PCP notification, specialist contact, results routing responsibility]

(Do not fabricate details. For missing critical data such as BP, urine microscopy, or protein quantification, explicitly note the gap and plan to obtain. Ensure the note reflects findings and decisions specific to this encounter; avoid auto-populated normal findings not personally verified.)