jump to navigation

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.)

“Patient with vaginal bleeding…” Case Conclusion August 7, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , add a comment

Case re-cap:

Your radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours…

Case conclusion:

The bleeding 42-year-old woman was quite ill upon arrival to the ED, with blood pressure of 96/52 mm Hg, heart rate of 124 beats/min, respiratory rate of 17 breaths/ min and oxygen saturation of 97% on room air. Two large-bore peripheral IVs were placed, and fluid resuscitation with normal saline boluses was started. On physical exam, she was bleeding heavily from the cervical os, and her uterus was large, firm, and irregularly shaped. A pregnancy test was negative. You started treatment with conjugated equine estrogen 25 mg IV. Her initial CBC showed a hemoglobin of 6.8 g/dL, and she was transfused with 2 units of packed red blood cells. After receiving the normal saline boluses and packed red blood cells, there was improvement in her vital signs. Her bleeding began to slow, and after a second dose of IV estrogen 4 hours later, the bleeding stopped completely and she was admitted to the gynecology service in stable condition. As the patient had completed child-bearing and had had little success with medical management of her heavy bleeding in the past, she elected for hysterectomy, which was performed the next day.

Download free risk management pitfalls for Vaginal Bleeding In Nonpregnant Patients.

Congratulations to Chris Stahmer, Anusha Chari, Joncheah, Shayne Calleja, and Rachael N.K. — this month’s winners get a free copy of the latest issue of Emergency Medicine Practice on this topic: Emergency Department Management Of Vaginal Bleeding In The Nonpregnant Patient. Didn’t win but want to get a complete systematic, evidence-based review on this topic? Purchase the issue today including 4 CME credits!

Patient with vaginal bleeding… July 26, 2013

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , 14comments

Your radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours…

How would you manage this patient?

(Leave a comment to be eligible to receive a free copy of the August 2013 issue of Emergency Medicine Practice, which features this case. To do so, simply enter your response in the comments box. The deadline to enter is August 6th.)

A case of Rhabdomyolysis… March 1, 2012

Posted by Andy Jagoda, MD in : Musculoskeletal Emergencies, Renal and Genitourinary Emergencies, Trauma , 11comments

A nurse informs you of a new patient who “just doesn’t look well.” You assess the patient, a 69-year-old woman who is coughing up green sputum, saturating 89% on room air, and is febrile, tachypneic, and tachycardic with a blood pressure of 86/40 mm Hg. The patient’s daughter informs you that her mother was just released from the hospital 6 days earlier after being treated for pneumonia. You suspect septic shock and instruct the nurse to place a nonrebreather mask on the patient. You administer broad-spectrum antibiotics, draw cultures and labs (including a venous lactate and a cardiac panel), and initiate a 30-cc/kg crystalloid infusion. The blood pressure normalizes, so you breathe a sigh of relief, but soon after, the lactate returns elevated at 8 mmol/L, which confirms your suspicion for severe sepsis. The nurse places a Foley catheter and reports that there is scant and “dark” urine in the bag. The WBC count returns at 18.4, and her BUN and Cr are 32 and 5.5, respectively. You note that the BUN:Cr ratio is odd, considering her previously normal renal function; you expected an increased ratio due to prerenal azotemia from severe sepsis. You then notice that the CK level is 67,000 U/L with normal MB fraction. To confirm your hunch, you check the UA, which returns positive for “blood” but does not show any red blood cells in the sediment.

This case reminds you that rhabdomyolysis has many causes, but the treatment in all cases is based on an aggressive hydration strategy. You recall that sodium bicarbonate infusion may be indicated and wonder: when, and how should it be initiated? You also wonder, “Is there anything else I can do for this patient that would mitigate against complications from renal failure?”

What’s Your Next Step?

(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is March 6th.)

“Chief Complaint: Lethargy” … Case Conclusion February 6, 2012

Posted by Andy Jagoda, MD in : Cardiovascular, Gastrointestinal, Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , add a comment

The Conclusion Is…

The local Poison Control Center was promptly contacted and the controversies, risks, and benefits of HBO treatment were discussed. The local HBO center was contacted and because of its close proximity and because the patient had evidence of end-organ damage, the decision was made to transfer the patient for treatment. She received an aspirin for her ECG changes and was transferred with ongoing NBO therapy. The HBO treatment was provided without complication. The patient was admitted to the medical service, after which she underwent 2 additional “dives” during her hospitalization. Her 6-hour troponin I level peaked at 2.1 mg/L, and an ECG obtained at that time had returned to her baseline. Subsequent cardiac biomarkers were obtained 12 hours after presentation and were normal. She remained hemodynamically stable and free of symptoms during her hospitalization. After undergoing stress echocardiography testing on hospital day 2, which did not reveal evidence of reversible myocardial ischemia, she was discharged on hospital day 3. At a 6-week clinic follow-up appointment, she denied any symptoms and had a normal examination. However, she said she had sold her apartment and moved in with her son’s family.

Congratulations to Dr. Aziz, Dr. Garcia, Dr. Koury, Dr. Luvetz, and Dr. Stanley — this week’s winners of Emergency Medicine Practice’sAdvances In Diagnosis And Management Of Hypokalemic And Hyperkalemic Emergencies!” For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for detecting hypokalemia and hyperkalemia, read this issue.

Chief Complaint: Lethargy… January 25, 2012

Posted by Andy Jagoda, MD in : Cardiovascular, Gastrointestinal, Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , 28comments

EMS brings in a 64-year-old gentleman with a chief complaint of lethargy. On arrival, the patient is bradycardic at 40 beats per minute with a normal blood pressure. You ask the nurse to immediately move the man to the resuscitation bay, obtain intravenous access, draw a rainbow of labs, and obtain an ECG. The EMS report states that they found him at home alone, unable to ambulate without assistance. The patient tells you that he has missed dialysis for the past few sessions because he did not have the energy to make it to clinic. You obtain an ECG and immediately notice concerning abnormalities.

What’s Your Next Step?

(Enter to win the latest issue of Emergency Medicine Practice, including CME, by submitting your answer to the question above. To do so, simply enter your response in the comments box. The deadline to enter is February 6th.)

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 07-21-2019
© EB Medicine