“If you are given a second chance in life, don’t blow it,” you advise your eager resident. It has been an overwhelmingly busy day in the department. Interspersed between the motor vehicle collisions, hypoxic and hypotensive CHF exacerbations, and patients with florid sepsis, your team is trying to see and help all of the ankle pains, throat pains, and dysuria that have also walked through the waiting room doors. The neighborhood clinics are completely overbooked, and your department has been dealing with the overflow all week.

Your resident has three charts in her hand and has just finished presenting the two sicker patients to be seen. Her third patient is a 60-year-old, otherwise healthy male, who was just here last week for nausea, dysuria, and “feeling unwell”. He was diagnosed with a UTI at that time, and given a prescription for cephalexin. Per his records, he had reported some unprotected intercourse also, so he was empirically treated with azithromycin and ceftriaxone for gonorrhea and chlamydia. The patient went home and his dysuria did not improve with the antibiotics. He couldn’t afford the co-pay to be seen in our clinic, so he returned to the ED.

On exam, the patient is sitting comfortably in bed, in no acute distress. He has his hospital gown on backwards with the ties and opening in the front—a sure sign that he’s not your typical ED frequent-flier. He’s happy to talk to you about his persistent symptoms, and does not appear angry or disenchanted that this is his second ED visit for the same problem. His vital signs are normal and his chest, abdominal, back, and genitourinary exam is benign. You take a moment to review the patient’s previous urinalysis results with your resident and note that a week ago he had trace leuk esterase, trace ketones, 10 RBC’s, 1 WBC, <1 squamous epi, negative nitrite, and no bacteria. His urine culture from that last visit has not showed any growth to date.

You ask your resident what her plan is for the patient, and she tells you that she wants to give him a stronger antibiotic for his resistant hemorrhagic cystitis and have him follow up with urology as an outpatient. After a deep breath and pause for effect, you remind her that the plan for outpatient follow-up didn’t really pan out the last time the patient was seen in the ED, and you ask her to look at the UA from last week again. “Do you think he has a bladder infection? What else could this be?” She spouts off a differential including trauma, renal stones, nephropathies, glomerulonephritis, cancer, BPH, and even schistosomiasis and renal AVM’s just because you are testing her. You decide to capitalize on this teaching moment and have her wheel in the ultrasound machine to the patient’s bedside.

As you scan through his kidneys bilaterally, you talk some more to your patient and realize that his dysuria is really more of a difficulty starting and maintaining his stream. He has had some nocturia and has noticed some intermittent specks of blood in the toilet after he urinates. His bedside renal ultrasound does not demonstrate any obvious abnormalities other than mild bilateral hydronephrosis, so you turn your attention to the patient’s bladder. What do you see on your bedside bladder scan? (Images 1 & 2) What’s the next step in your treatment plan?



What does the ultrasound show? What is the next step in your treatment plan?  Conclusion on NEXT page



# attendingRamesh Karra 2014-11-01 22:20
mass effect; ?bladder CA/prostate CA; CT scan abdomen

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