Cardiotoxicity January 29, 2014

Posted by Andy Jagoda, MD in: Uncategorized , 19 comments

Late one evening, a 32-year-old woman is brought to your ED via EMS after her boyfriend found her slumped over in a chair. He states that they were arguing last evening and that she was quite upset. Her boyfriend provides a medical history significant for migraine headaches, and he knows that she is taking verapamil for the same. Her fingerstick glucose is normal, and she has a heart rate of 28 beats/min and a blood pressure of 74/36 mm Hg. Consider what the best initial step in management for this patient would be — Is there a role for GI decontamination? What about hemodialysis?

Submit your diagnosis in the comments box below, and be sure to check back on February 8 to see if you were correct!

Case Conclusion — Urinary Retention Complications January 6, 2014

Posted by Andy Jagoda, MD in: Uncategorized , add a comment

Case 1:

A quick physical examination revealed only a distended bladder for the 72-year-old man. A urethral catheter was placed, and 700 mL of urine was obtained, with much relief for the patient. Not forgetting the patient’s presentation and his stumble while changing stretchers, you decided to perform a thorough neurological examination, and you found nearly absent rectal tone and absence of sensation and vibration below T11. Urgent MRI confirmed your diagnosis of spinal cord compression. You consulted neurosurgery, and the patient was admitted for decompressive laminectomy and eventual chemotherapy.

Case 2:

After taking the history of the 46-year-old febrile woman with HIV and giving her a thorough physical examination, you performed a rectal examination, which showed good rectal tone and no evidence of obstruction. You then performed a pelvic examination (with a chaperone present), and it showed vesicular lesions suggestive of herpes. Adequate pain control was achieved. Ultrasound showed a fully distended bladder. You gave the patient acetaminophen, IV acyclovir, and IV fluids, and you started cardiorespiratory monitoring. You performed complete bladder decompression using a 16F Foley and sent the urine for urinalysis and culture. The urinalysis returned positive for white blood cells, so you gave her IV ceftriaxone and admitted her to medicine for IV antibiotics, IV fluids, and antivirals.

Congratulations to this month’s winners!  You will receive a free copy of the latest issue of Emergency Medicine Practice: An Evidence-Based Approach To Emergency Department Management of Acute Urinary Retention. If you did not win this month, you can still read part of the issue — click here to download a free copy of this month’s Risk Management Pitfalls!

Urinary Retention Complications January 2, 2014

Posted by Andy Jagoda, MD in: Renal and Genitourinary Emergencies , 1 comment so far

Case 1:

It’s 2:00 PM and you are about to finally grab some lunch, but in comes a 72-year-old man with a history of large cell lymphoma for the past 15 years. He complains of dribbling urinary frequency, which has worsened over 1 day after being prescribed an antibiotic by his doctor for a UTI. The nurse asks him to walk to another stretcher, and as he gets up, he stumbles and catches himself with his hands. As you prepare to do the bladder ultrasound, you wonder why he stumbled…

Case 2:

It’s finally 6:30 PM, with just 30 minutes until relief arrives. You are spending the last half hour of your shift tying up the loose ends with your current patients when a 46-year-old febrile woman with a  history of active intravenous drug abuse and HIV comes in. She is in excruciating discomfort and tells you that she has not urinated in 2 days. You wonder if that is possible, and why…

What would you do to manage these patients?

(Leave a comment with your solutions to this month’s cases to be eligible to receive a free copy of the January 2014 issue of Emergency Medicine Practice.  The deadline to enter is January 6th.)