Case 25

83F w/PMH s/f HTN, HLD, CAD (on ASA & plavix), AAA s/p unsuccessful repair, COPD and multiple UTIs p/w vaginal bleeding which began earlier today.  Also associated with R sided low back pain and lower abd pain x 1 day.  Last night, c/o dysuria and urgency.  Pt noticed dark blood when wiping below. No clot visualized. Denies fever, chills, cp/sob, n/v/d or constipation, melena/hematochezia, change in appetite.  

ROS:
Constitutional:  No fevers/chills
Cardiac: No CP, SOB or edema
Resp: No cough or resp distress
GI: No nausea, vomiting, diarrhea. No constipation. Nl appetite.
GU: Per HPI
MS: R lateral back pain. No arthralgias or myalgias. 

PE:
Vitals: T 98.2F, BP 112/70, P 76, RR 18, 95% O2Sats on RA
ABD: Normal bowel sounds; distended abdomen. Suprapubic tenderness to palpation. 
GU: External genitalia normal in appearance. No abrasions or lacerations noted. No gross blood on bimanual exam.  Hematuria noted.
MSS: Normal ROM. No edema. Mild R CVA tenderness to palpation 

Questions:

  1. What do you see in Image A and B below?
  2. What are the clinical implications seen in Image C?
  3. What is your next course of action? 
  4. What is your differential diagnoses?  
Image A

Image A

Image B

Image B

Image C

Image C

Answers:

  1. In the associated figures, you can see an echogenic collection in the bladder. The collection is visualized in both transverse and sagital views. Since urine would be excpected to be anechoic, it is reasonable to assume that this collection consists of blood. The patient was found to have hematuria.
  2. In this image, we see an object in the bladder that has an echogenic and circular outer component with an anechoic center. The object is a Foley Catheter located within the bladder. The Foley is floating on top of the bloody collection and does not appear to be draining the distended bladder. 
  3. The bladder is not draining and we must act to relieve the distension. Possible causes of this include a malfunctioning catheter, a full urine bag that needs to be changed or an obstruction along the course of the catheter secondary to a clot or kink in the tubing. It is recommended to address each of these possibilities until the cause is found.
  4. Acute Poststreptococcal Glomerulonephritis
    Anti-GBM Antibody Disease
    Hemolytic-Uremic Syndrome
    Henoch-Schoenlein Purpura
    IgA Nephropathy
    Systemic Lupus Erythematosus
    Urinary Tract Infection
    Urolithiasis