#003 Curveball Case Study - Fluid in the abdomen

FY2 in ED Resus

77F BIBA with pyrexia and abdominal pain

Tachycardic, febrile and hypotensive. Poor urine output.

Ovarian Ca

Osteoarthritis

HTN

T2DM

Cataracts

Bloods – WCC 14, Urea 19.5, Creatinine 220, CRP 74

Bladder scan – >1000ml

Initial impression – Urinary retention and urosepsis

Plan

IVFs

Catheter

IV Abx

Cultures

Refer to Care of the Elderly

Review one hour later

Patient had minimal urine output from catheter despite correction of tachycardia with IV fluid. Ongoing abdominal pain with a persistently raised lactate from VBGs

Plan

Decision for CTAP ?acute abdomen

CT-AP report: obstructive ureteric stone, empty bladder, abdominal ascites and known ovarian malignancy.

Patient had a nephrostomy, then significantly improved after managing the source of her sepsis

Learning point - Bladder scan mistook ascites for urinary retention. Be aware that bladder scans are not perfect, and to correlate with your clinical assessment. If in doubt, then you can always get a repeat bladder scan done (potentially by a different practitioner), or see if you can borrow an ultrasound machine and use the curvilinear probe to identify urinary retention - or ask your SHO to have a go.