What is the diagnosis and management for a 68-year-old male patient with sudden onset of constipation, anuria, hypogastric pain, melena, hematochezia, impaired renal function (elevated creatinine), hypothyroidism (elevated TSH), urinary tract infection (pyuria and hematuria), and significant anemia (drop in hemoglobin), with a history of diabetes (HBA1C 6.4)?

Comprehensive Diagnosis and Management

Primary Diagnoses

This 68-year-old male presents with multiple concurrent acute and chronic conditions requiring systematic evaluation and management: acute lower gastrointestinal bleeding with anemia and thrombocytopenia, urinary tract infection with pyuria and hematuria, severe hypothyroidism, urinary retention secondary to benign prostatic enlargement, and fecal impaction with recent bowel movement.

1. Acute Lower GI Bleeding with Anemia and Thrombocytopenia

• The hemoglobin drop from 13.4 to 9.8 g/dL with concurrent platelet decline from 123 to 97 requires immediate assessment for severity and risk stratification 1
• Blood typing and cross-matching should be completed given the significant hemoglobin drop 1
• The melena and hematochezia following hard stools suggest anorectal pathology (hemorrhoids, anal fissure, or mucosal trauma from fecal impaction) rather than upper GI bleeding 1
• Digital rectal examination and flexible sigmoidoscopy are essential to rule out structural pathology and assess for hemorrhoidal disease, fissures, or other anorectal causes 1
• The thrombocytopenia (97) with anemia requires evaluation for microangiopathic process, though the absence of schistocytes on peripheral smear would argue against hemolytic uremic syndrome or thrombotic thrombocytopenic purpura 1
• Monitor CBC daily until platelet count stabilizes or increases 1

2. Urinary Tract Infection with Pyuria and Hematuria

• Pyuria "numerous to count" with hematuria "numerous to count" in the setting of recent urinary retention indicates complicated UTI requiring treatment 2
• The urinalysis findings combined with recent catheterization (FBC insertion) place this patient at high risk for catheter-associated UTI 2
• Urine culture with antimicrobial susceptibility testing is mandatory before initiating empiric antibiotics 2
• Empiric antibiotic therapy should be started immediately after obtaining cultures, with dose adjustment for renal function (creatinine 0.940) 2
• Escherichia coli remains the most common pathogen, but catheterization increases risk of resistant organisms 2

3. Severe Primary Hypothyroidism

• TSH of 70.29 mIU/L represents severe hypothyroidism requiring thyroid hormone replacement 3
• Free T4 and free T3 levels should be obtained to confirm primary hypothyroidism
• Anti-TPO antibodies should be measured to evaluate for autoimmune thyroiditis, which may be associated with the proteinuria and hematuria 3
• Levothyroxine should be initiated at low dose (25-50 mcg daily) given age >65 years and diabetes, with gradual titration every 4-6 weeks based on TSH levels
• Hypothyroidism may contribute to constipation and should improve with treatment

4. Urinary Retention Secondary to Benign Prostatic Enlargement

• The patient has recurrent urinary retention requiring catheterization, indicating significant bladder outlet obstruction 1
• Post-void residual volume measurement is needed once catheter is removed 1
• Alpha-blocker therapy (tamsulosin 0.4 mg daily or alfuzosin 10 mg daily) should be initiated to improve voiding and reduce retention risk 1
• Urology consultation is warranted for consideration of interventional therapy given recurrent retention episodes 1
• Assess for contributing factors including constipation/fecal impaction and medications that may worsen retention 1

5. Constipation with Recent Fecal Impaction

• Fecal impaction has been addressed with bowel movement, but the hard stools causing anorectal bleeding require ongoing management 1
• Hypothyroidism is a significant contributing factor to constipation and should improve with thyroid replacement
• Initiate bowel regimen with stool softeners (docusate 100 mg twice daily) and osmotic laxatives (polyethylene glycol 17 g daily) 1
• Increase dietary fiber intake gradually and ensure adequate hydration 1
• Avoid straining during defecation to prevent recurrent anorectal bleeding 1

6. Diabetes Mellitus (Controlled)

• HbA1c of 6.4% indicates well-controlled diabetes, but patient reports no maintenance medications
• Fasting blood sugar of 72.56 mg/dL is at lower limit of normal
• Initiate metformin 500 mg daily with meals if no contraindications, with gradual titration based on glucose monitoring
• Diabetes increases risk of infections and may contribute to bladder dysfunction 1

Lacking Diagnostics

Immediate/Urgent (Within 24 Hours)

1. Complete blood count with peripheral smear - to evaluate for schistocytes and assess severity of anemia and thrombocytopenia 1
2. Reticulocyte count, LDH, haptoglobin, indirect bilirubin - to evaluate for hemolysis 1
3. Prothrombin time, aPTT, fibrinogen - to assess coagulation status 1
4. Urine culture with antimicrobial susceptibilities - to guide antibiotic therapy 2
5. Stool culture including Shiga toxin testing - given hematochezia and thrombocytopenia to rule out STEC infection 1
6. Free T4 and free T3 levels - to confirm primary hypothyroidism 3
7. Serum ferritin, iron studies - to evaluate iron deficiency anemia 1
8. Type and cross-match - given significant anemia 1

Within 48-72 Hours

1. Flexible sigmoidoscopy or anoscopy - to identify source of lower GI bleeding 1
2. Anti-TPO antibodies - to evaluate for autoimmune thyroiditis 3
3. 24-hour urine collection for protein, calcium, uric acid, oxalate, citrate - to evaluate metabolic causes of hematuria 4
4. Post-void residual volume measurement - once catheter removed 1
5. Repeat hemoglobin and platelet count - to assess trend 1

Within 1 Week

1. Upper GI endoscopy with small bowel biopsies - if anemia persists or worsens despite treatment of lower GI source, to rule out celiac disease and upper GI pathology 1
2. Colonoscopy - if sigmoidoscopy does not identify bleeding source and anemia is transfusion-dependent 1
3. Urologic evaluation - for management of recurrent urinary retention 1

SOAP Format for Chart Documentation

SUBJECTIVE

Chief Complaint: Melena and hematochezia, urinary retention

History of Present Illness: 68-year-old male with sudden onset constipation 1 day prior to admission, followed by anuria with hypogastric pain relieved by Foley catheter insertion. Patient reports minimal melena and hematochezia on hospital day 6, attributed to passage of hard stools after resolution of fecal impaction. Patient had bowel movement prior to bleeding episode.

Past Medical History:

• Diabetes mellitus (HbA1c 6.4%), not on medications
• Recurrent urinary retention (admitted last year for anuria)
• Benign prostatic enlargement
• Recent fecal impaction (this admission)

Medications: None reported

Allergies: NKDA

Social History: [Document as appropriate]

Family History: [Document as appropriate]

Review of Systems:

• GI: Constipation, melena, hematochezia (minimal), abdominal pain (resolved)
• GU: Anuria (resolved with catheterization), hypogastric pain (resolved)
• Constitutional: Denies fever, chills, weight loss
• Other systems: Negative except as noted

OBJECTIVE

Vital Signs: [Document BP, HR, RR, Temp, O2 sat, weight]

Physical Examination:

• General: [Document appearance, distress level]
• HEENT: [Document thyroid examination]
• Cardiovascular: Regular rate and rhythm (per ECG)
• Respiratory: [Document lung examination]
• Abdomen: [Document tenderness, distension, bowel sounds, masses]
• Rectal: [Document tone, masses, hemorrhoids, fissures, stool color, occult blood]
• Genitourinary: Foley catheter in place, [document prostate size if examined]
• Extremities: [Document edema]
• Neurological: [Document mental status, focal deficits]

Laboratory Data:

• Admission Labs:

  • Hemoglobin: 13.4 g/dL → Current: 9.8 g/dL (↓ 3.6 g/dL)
  • Platelets: 123 K/µL → Current: 97 K/µL (↓ 26 K/µL)
  • WBC: 5.55 K/µL
  • Creatinine: 0.940 mg/dL
  • HbA1c: 6.4%
  • Fasting blood sugar: 72.56 mg/dL
  • LDL: 70 mg/dL
  • TSH: 70.29 mIU/L (markedly elevated)

• Urinalysis:

  • Pyuria: Numerous to count
  • Hematuria: Numerous to count
  • [Document protein, glucose, ketones, specific gravity, pH]

• 12-Lead ECG: Sinus rhythm

Imaging: [Document any abdominal imaging if performed]

ASSESSMENT

1. Acute lower gastrointestinal bleeding with anemia (ICD-10: K92.2, D62)

   • Hemoglobin drop 13.4 → 9.8 g/dL
   • Likely anorectal source (hemorrhoids vs fissure) secondary to hard stools
   • Requires sigmoidoscopy/anoscopy for source identification

2. Thrombocytopenia (ICD-10: D69.6)

   • Platelets 123 → 97 K/µL
   • Differential includes dilutional, consumptive, or microangiopathic process
   • Requires peripheral smear and hemolysis workup

3. Complicated urinary tract infection with pyuria and hematuria (ICD-10: N39.0)

   • Numerous pyuria and hematuria on urinalysis
   • Recent catheterization increases infection risk
   • Awaiting urine culture results

4. Severe primary hypothyroidism (ICD-10: E03.9)

   • TSH 70.29 mIU/L (markedly elevated)
   • Contributing to constipation
   • Requires thyroid hormone replacement

5. Urinary retention secondary to benign prostatic enlargement (ICD-10: N40.1, R33.8)

   • Recurrent episodes requiring catheterization
   • Foley catheter currently in place
   • Requires urology consultation

6. Constipation with recent fecal impaction, resolved (ICD-10: K59.00, K56.41)

   • Contributing to anorectal bleeding
   • Related to hypothyroidism

7. Diabetes mellitus, type 2, controlled (ICD-10: E11.9)

   • HbA1c 6.4%, not on medications
   • Requires initiation of therapy

PLAN

1. Acute Lower GI Bleeding with Anemia:

• NPO after midnight for sigmoidoscopy tomorrow morning 1
• Type and cross-match 2 units PRBCs 1
• Transfuse 1 unit PRBCs if Hgb <7 g/dL or symptomatic (chest pain, dyspnea, tachycardia) 1
• Serial CBC every 8 hours until stable 1
• Flexible sigmoidoscopy in AM to identify bleeding source 1
• Stool softeners: Docusate sodium 100 mg PO BID 1
• Avoid NSAIDs, aspirin, anticoagulants
• If sigmoidoscopy negative and anemia persists: upper endoscopy with small bowel biopsies 1
• Iron supplementation once acute bleeding controlled: Ferrous sulfate 325 mg PO daily 1

2. Thrombocytopenia:

• Peripheral blood smear to evaluate for schistocytes 1
• Hemolysis workup: Reticulocyte count, LDH, haptoglobin, indirect bilirubin 1
• Coagulation studies: PT, aPTT, fibrinogen 1
• Monitor platelet count daily 1
• Hold platelet transfusion unless active bleeding or platelets <10 K/µL 1
• Discuss with blood bank regarding possible immune-mediated process 1

3. Complicated UTI:

• Urine culture with sensitivities (send immediately) 2
• Empiric antibiotics: Ceftriaxone 1 g IV daily (adjust for renal function if needed) 2
• Narrow antibiotics based on culture results 2
• Remove Foley catheter once patient able to void spontaneously 2
• Repeat urinalysis after treatment completion 2
• Encourage oral hydration once tolerating PO

4. Severe Hypothyroidism:

• Free T4, Free T3 levels 3
• Anti-TPO antibodies 3
• Levothyroxine 25 mcg PO daily (low starting dose given age >65 and cardiac risk) 3
• Recheck TSH in 6 weeks, titrate by 12.5-25 mcg increments 3
• Endocrinology consultation for management
• Patient education regarding medication compliance and symptoms

5. Urinary Retention/BPE:

• Post-void residual measurement once catheter removed 1
• Alpha-blocker: Tamsulosin 0.4 mg PO daily at bedtime 1
• Trial of void in 24-48 hours after starting alpha-blocker 1
• Urology consultation for recurrent retention and consideration of interventional therapy 1
• Avoid anticholinergic medications 1

6. Constipation:

• Bowel regimen: Docusate 100 mg PO BID + Polyethylene glycol 17 g PO daily 1
• Increase dietary fiber gradually once tolerating regular diet 1
• Encourage adequate fluid intake (2 liters daily if no contraindication) 1
• Patient education: avoid straining, respond to urge promptly 1
• Reassess after thyroid replacement initiated (constipation should improve) 1

7. Diabetes Mellitus:

• Fingerstick blood glucose QID (AC and HS)
• Diabetic diet
• Metformin 500 mg PO daily with largest meal once tolerating PO and renal function stable
• Titrate metformin by 500 mg weekly to target dose 1000 mg BID based on glucose control
• HbA1c recheck in 3 months
• Diabetes education regarding diet, exercise, medication compliance

Additional Orders:

• Diet: NPO after midnight for sigmoidoscopy, then advance as tolerated
• Activity: Bed rest with bathroom privileges
• DVT prophylaxis: Sequential compression devices (hold pharmacologic prophylaxis given active GI bleeding)
• Fall precautions given anemia and hypothyroidism
• Daily weights
• Strict intake and output monitoring

Consultations:

• Gastroenterology for sigmoidoscopy (urgent)
• Urology for recurrent urinary retention (within 48 hours)
• Endocrinology for severe hypothyroidism (within 1 week)

Patient/Family Education:

• Explained diagnoses, testing plan, and treatment approach
• Discussed transfusion risks/benefits
• Emphasized importance of medication compliance, especially thyroid replacement
• Instructed to report worsening bleeding, dizziness, chest pain, shortness of breath

Disposition:

• Admit to medical floor with telemetry monitoring given anemia
• Reassess daily and adjust plan based on test results and clinical response

Critical Pitfalls to Avoid

• Do not assume hemorrhoids are the sole cause of anemia without endoscopic evaluation - dual pathology occurs in 10-15% of patients 1
• Do not overlook the possibility of hemolytic uremic syndrome given the combination of anemia, thrombocytopenia, and hematuria, though renal function is preserved 5
• Do not start thyroid replacement at full dose in elderly patients with cardiac risk factors - start low (25 mcg) and titrate slowly 3
• Do not remove Foley catheter without initiating alpha-blocker therapy first given recurrent retention history 1
• Do not attribute all hematuria to UTI - metabolic abnormalities and glomerular disease must be considered if hematuria persists after infection treatment 4, 3
• Monitor for iron deficiency even after acute bleeding resolves, as continued supplementation for 3 months is needed to replenish stores 1