Case Study Discussion : 65 years Man unable to urinate for 65 years

A 64-year-old man presents to the  (ED) because of an inability to urinate for the past 24 hours. 

In addition, he complains of an unintentional weight loss of 20 lb over the past 6 months , night sweats, and generalized fatigue. On examination, he is thin and in moderate distress. His BP is 168/92 mm Hg, heart rate is 102 beats per minute, temperature is 37.7°C (98.8°F),

and respiratory rate is 22 breaths per minute. The abdominal examination reveals

a tender mass in the suprapubic area. 

rectal examination, the prostate is firm, nontender, and somewhat irregular.

What is the most likely diagnosis

 How would you confirm the diagnosis

 What is the next step in treatment

 A 64-year-old man presents with an inability to void for the past 24 hours

and a tender mass in the lower abdomen. The patient has signs and symptoms

suggestive of prostate cancer, including unintentional weight loss, night sweats, a

decrease in energy, and an enlarged irregular firm prostate gland.

• Most likely diagnosis: Acute urinary retention likely due to prostate cancer.

• Confirming the diagnosis: Thorough history and physical examination including a rectal examination, urinalysis, electrolytes and renal function tests, along

with bedside ultrasound, if available. Prostate-specific antigen may help in the

diagnosis of neoplastic disease if results will be available in the ED.

• Next steps in treatment: Draining the bladder by inserting a urethral catheter

should relieve the patient’s pain; if not, a suprapubic catheter can be placed.

Treatment of the underlying disease process is also necessary.

Malignant causes of LBP , etiology , Clincal Picture , Diagnostics and Treatment

Aetiology

Common Cause metastatic  breast, prostate, lung 

May also be primary loke multiple myeloma, leukemia, lymphoma

Clinical Symptoms Analysis

Pain lasting longer than 1 month, worse at night, unrelieved by rest; unexplained

weight loss; 

mild tomoderate spinal tenderness

Diagnostic tools

CBC, ESR,

plain x-ray, CT,

MRI

Treatment in Emergency Departement 

intravenous dexamethasone

and  refer for radiation therapy

Spinal Infection , etiology , Clinical Picture , Diagnostics and Treatment

Etiology

Most commonly due

to Staphylococcus.aureus

Risk Factors

intravenous drug use

elderly, immunocompromised, alcoholism, recent bacterial

Signs and Symptoms

infection or back trauma

Back pain (even at rest/

night), fever, midline

cultures, tenderness

along spine.

Focal neurologic deficits as late finding

Diagnostics 

CBC, ESR,

 plain x-ray 

C.T

MRI - preferred

Treatment

Intravenous

antibiotics,

surgical drainage

and

decompression

Red Flag Signs and Symptoms of Low Back Pain LBP

 Patients younger than 18 years old or older than 50 years 

Significant trauma (or mild trauma in patients older than 50 years) 

Chronic steroid use 

Osteoporosis 

History of cancer Recent infection 

Immunocompromise 

History of intravenous drug use 

Pain worse at night, 

lasting longer than 6 weeks,

 or refractory to analgesics and rest 

Associated systemic symptoms (fever, unexplained weight loss, malaise, night sweats, diaphoresis, nausea, syncope) 

Acute onset Use of anticoagulants or coagulopathy 

Abnormal vital signs (including unequal blood pressures or pulse deficits) 

Neurologic deficits (including extremity weakness, numbness, paresthesias, loss of rectal sphincter tone, urinary retention)

Cauda Equina Syndrome Case Study , Cardinal Signs

A 57-year-old man 

  one month history of worsening low back pain 

 radiates down the back of both legs and suddenly increased yesterday.

 For the past 2 days,  have difficulty voiding

 skin around his anus feels numb when he wipes with toilet tissue. 

He denies prior trauma to or surgery on his back. 

- Most likely diagnosis: Cauda equine syndrome

Aetiology Central disk herniation multiple, involving bilateral nerve roots 

  the next diagnostic step MRI

Why Cauda Equina and not other causes of LBP because cardinal signs of Cauda equina syndrome are 

, urinary retention and overflow incontinence, decreased rectal tone, saddle anesthesia 

Past Surgical History in Clinical Examination

 Past surgical history: Date and type of procedure performed, indication, and

outcome. Laparoscopy versus laparotomy should be distinguished. Surgeon

and hospital name/location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should

be delineated including, for example, anesthetic complications and difficult

intubations.

Dyspnea on Exertion in a 46-Year-Old Man

Dyspnea on Exertion in a 46-Year-Old Man  CME

	BACKGROUND A man presents to the ED with a 5-day history of progressive dyspnea on exertion and mild flu-like symptoms. He also complains about night sweats and an intermittent fever. What's the diagnosis? HINT: Note the location of the mass.

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