Value of the Secondary Assessment
Sometimes things are not as they seem. One afternoon an elderly patient walked into the ER with a complaint of difficulty breathing. He said he had a gradual onset of shortness of breath over the past couple days. It seemed to be worse with activity or when sitting. He denied any pain associated. He also denied cough or fever.
He had some problems with mild COPD in the past, but usually that improved with using his inhaler. He said this felt different as he didn’t have the chest tightness or wheezing that he would usually have with episodes of shortness of breath.
It would be easy to get tunnel vision when the patient mentioned the past history of COPD and attribute his dyspnea to a COPD exacerbation. However, I expanded my enquiry by proceeding to a review of systems or as known by EMTs a secondary assessment. As noted, the patient denied chest pain and also denied edema. He had no GI complaints. However, he did admit to a chronic problem with difficulty voiding urine – poor stream and frequency. This had recently become worse over the past week to the point that he was just only able to pass a few drops of urine at a time, if any.
On exam, his vitals where WNL, except for a BP of 160/96. I found his lungs to be clear, but with decreased air entry bilaterally. His abdomen was distended due to a lower abdominal mass. He had no JVD, but had mild ankle edema.
With the patient’s consent, a urinary catheter was placed and over the next several hours several liters of urine where drained. Some of which was due to fluid that had collected in his body due to the inability of the kidneys to clear it. The patient’s dyspnea and BP very quickly improved.
Benign prostatic hypertrophy was the cause of this patient’s urinary retention. The urinary retention led to a very distended bladder which limited diaphragm movement, impairing his ability to get adequate lung volumes.Therefore he was short of breath especially when sitting. Also, the urinary retention was causing renal failure which contributed to dyspnea due to fluid retention and congestion of the lungs. His blood pressure normalized after the bladder was drained.
The patient fully recovered. He was discharged home with a Foley catheter and scheduled to see a urologist for a transurethral prostatectomy. This case is a good example of why we do a review of systems. Patients may not mention important aspects of their history unless directly asked.
Marven Ewen, MD