John is a 43 year old, white male who is single, has no children, is unemployed, and is uninsured. He has been treated for hypertension and erectile dysfunction for the past 3 years and has presented to the emergency department four times in the last month with complaints of not being able to urinate. His home medications include Aspirin 81 mg daily, Plavix 75 mg daily, Metoprolol 50 mg twice a day, and Viagra as needed. He has developed urinary retention and has been catheterizing himself at home for approximately one week with the foley catheter he pulled out of the trash at his last emergency room visit. His older sister, the only surviving relative, has brought him to the emergency department with confusion, hypothermia, tachycardia, tachypnea, hypotension.

1) Based on the above symptoms what other assessments, tests or procedures would the MD order or perform to help diagnosis the problem?

2) What results would you expect to find and why?

3) Based on your results what is the cause and pathology?

4) What are the patient’s risk factors?

Solution

1. Additional assessments, tests, or procedures the MD may order or perform to help diagnose the problem include:

• Complete blood count (CBC) and comprehensive metabolic panel (CMP) to assess for infection, electrolyte abnormalities, and kidney function.
• Urinalysis and urine culture to evaluate for urinary tract infection (UTI) and assess for presence of bacteria in the urine.
• Renal ultrasound or abdominal/pelvic imaging to assess for any structural abnormalities or obstruction in the urinary tract.
• Prostate-specific antigen (PSA) blood test and digital rectal examination (DRE) to evaluate prostate health and assess for prostate enlargement or cancer.
• Neurological examination to assess for any neurological issues affecting bladder function.
• Cystoscopy to directly visualize the bladder and urethra and evaluate for any abnormalities or blockages.

2. Expected results and rationale:

• CBC may show elevated white blood cell count if there is an underlying infection.
• CMP may reveal electrolyte imbalances such as hyponatremia or hyperkalemia due to urinary retention and dehydration.
• Urinalysis may show presence of bacteria, white blood cells, and blood, indicating urinary tract infection or inflammation.
• Urine culture may confirm the presence of bacteria and help guide antibiotic therapy.
• Renal ultrasound or imaging may reveal enlarged prostate, urinary stones, or other structural abnormalities.
• Elevated PSA levels or abnormal DRE findings may indicate prostate enlargement or prostate cancer.
• Cystoscopy may reveal urethral strictures, bladder stones, or other obstructions.

3. Based on the results, the cause and pathology of the patient’s symptoms may include:

• Urinary retention due to obstruction, such as enlarged prostate (benign prostatic hyperplasia) or urethral stricture.
• Urinary tract infection (UTI) contributing to urinary symptoms and systemic symptoms such as confusion, hypothermia, tachycardia, tachypnea, and hypotension.
• Dehydration and electrolyte imbalances due to prolonged urinary retention and inadequate fluid intake.
• Potential complications from self-catheterization with an unsterile foley catheter, leading to infection and systemic symptoms.

4. The patient’s risk factors include:

• Age (middle-aged)
• Gender (male)
• History of hypertension and erectile dysfunction
• Unemployment and lack of health insurance leading to delayed healthcare seeking and self-management practices
• Lack of social support and family history (only surviving relative is older sister) may contribute to delayed presentation and management of medical issues.