Consults- Memorable/Dismal/Ridiculous/Unique

[kitsunepixie]

I got one of those from the medicine service last year. Some incidental ortho finding on CT. Get consulted -> ticked off about getting consulted on an old fracture at 11pm. Go see the patient anyways and this poor old lady can't lift her BLE off the bed, 1.5 days of worsening saddle anesthesia, and incontinence of urine. Nobody on medicine had noticed she hadn't been able to lift her legs off the bed in the past day. She's in the OR within 6 hours for cauda equina syndrome.

Moral of the story. Even if the consulting service doesn't know what the heck they are doing you can still help a patient.

I had those consults not infrequently. It helps if the patient has a family member present to advocate for them, but it's unfortunate that the care team doesn't pick up on something big like that. Or, the old call about a patient actively herniating who was found unresponsive with a blown pupil on the ward, usually admitted for something vague, like "dehydration." You'd think it would only happen in the frail and elderly, but it happens with kids too (people who can't speak for themselves). We once had a kid transferred to a ward bed for overnight obs for dehydration from strep pharyngitis. The transferring hospital never mentioned a history of recent head injury and the child blew a pupil and was found to have a massive intracranial hemorrhage. Or, frequently with non-accidental head injuries, the baby is admitted for again something vague and is found to have broken ribs, head bleeds, retinal hemorrhages, bite marks, etc...

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[WinslowPringle]

ED NP: "I gotta guy in muh shop. He's coming in, saying he wants his dialysis catheter pulled. I'm consulting you to come pull it."
Me..............: "I'll come see him."

I'm expecting the worse. Best case is probably a soft admit to me for hospice arrangements; or at the least a really annoying period of time of paging on-call nephrologists to see what's up. I grab a consent form as I head down, no way I'm pulling an HD cath without consent and documentation. Go see "the guy" in "muh shop". Granted, he's dysarthric from a prior stroke and maybe homeless so there are some barriers there. But when I talk to him, the patient is very clear that he just wanted his dialysis catheter *cleaned*, not pulled; it had gotten dirty and the external wrapping type thing the dialysis centers around here usually wrap it with had come off - it was after hours and he couldn't go to the access center. No suicidal thoughts, not ready for hospice, not wanting an admit, not hiding a big ol' exit site infection in his chest, didn't need emergent dialysis, no hiding fistula needing a declot. Cleaned the catheter, fresh wrapping, he was happy and ready to go.

On one hand, I'm glad the practitioner didn't go with his first mishearing and pull it himself. On the other hand, that was 30 minutes of my life I won't get back...

 

[HighPriest]

ED NP: "I gotta guy in muh shop. He's coming in, saying he wants his dialysis catheter pulled. I'm consulting you to come pull it."
Me..............: "I'll come see him."

I'm expecting the worse. Best case is probably a soft admit to me for hospice arrangements; or at the least a really annoying period of time of paging on-call nephrologists to see what's up. I grab a consent form as I head down, no way I'm pulling an HD cath without consent and documentation. Go see "the guy" in "muh shop". Granted, he's dysarthric from a prior stroke and maybe homeless so there are some barriers there. But when I talk to him, the patient is very clear that he just wanted his dialysis catheter *cleaned*, not pulled; it had gotten dirty and the external wrapping type thing the dialysis centers around here usually wrap it with had come off - it was after hours and he couldn't go to the access center. No suicidal thoughts, not ready for hospice, not wanting an admit, not hiding a big ol' exit site infection in his chest, didn't need emergent dialysis, no hiding fistula needing a declot. Cleaned the catheter, fresh wrapping, he was happy and ready to go.

On one hand, I'm glad the practitioner didn't go with his first mishearing and pull it himself. On the other hand, that was 30 minutes of my life I won't get back...

Nah, you misunderstand. You were wasting your life UNTIL that NP called and gave you purpose. That's what all docs do when they're on call, they wilt like a flower until the ER gives them purpose.

 

[dpmd]

I had those consults not infrequently. It helps if the patient has a family member present to advocate for them, but it's unfortunate that the care team doesn't pick up on something big like that. Or, the old call about a patient actively herniating who was found unresponsive with a blown pupil on the ward, usually admitted for something vague, like "dehydration." You'd think it would only happen in the frail and elderly, but it happens with kids too (people who can't speak for themselves). We once had a kid transferred to a ward bed for overnight obs for dehydration from strep pharyngitis. The transferring hospital never mentioned a history of recent head injury and the child blew a pupil and was found to have a massive intracranial hemorrhage. Or, frequently with non-accidental head injuries, the baby is admitted for again something vague and is found to have broken ribs, head bleeds, retinal hemorrhages, bite marks, etc...

Not on the same level of severity but this reminds me of a story my chief resident told me when I was an intern. The night nurse asks him about the patient with cerebral palsy in room such and such. He notes the patient in said room does not have cerebral palsy and is in fact s/p total thyroidectomy. Orders stat calcium and is at the bedside while it gets administered. Patient who was all contracted up visibly relaxes and tells him thank you. Sad that no one noted the change in status but I never forgot to order delayed calcium level for a total thyroid and put some replacement orders in (especially if we were pretty sure we dinged the parathyroids).

 

[Raryn]

Not on the same level of severity but this reminds me of a story my chief resident told me when I was an intern. The night nurse asks him about the patient with cerebral palsy in room such and such. He notes the patient in said room does not have cerebral palsy and is in fact s/p total thyroidectomy. Orders stat calcium and is at the bedside while it gets administered. Patient who was all contracted up visibly relaxes and tells him thank you. Sad that no one noted the change in status but I never forgot to order delayed calcium level for a total thyroid and put some replacement orders in (especially if we were pretty sure we dinged the parathyroids).

Good catch.

You guys don't check a PTH in the PACU for every postop total thyroid? I'm used to it being a routine order. If the immediate postop PTH >10-15, the chance of significant hypopara in the next few days is basically nil.

 

[dpmd]

Good catch.

You guys don't check a PTH in the PACU for every postop total thyroid? I'm used to it being a routine order. If the immediate postop PTH >10-15, the chance of significant hypopara in the next few days is basically nil.

The hospital I trained at this was most likely a send out lab that wouldn't result in a worthwhile timeframe. I don't personally do thyroid now but I assist one guy with them. We do have immediate pth results available (because he uses it for the parathyroids I assist on) but i don't know if he uses it. Will have to mention it to him since he was at that other place most of his career so got used to making do with what you could get.

 

[WinslowPringle]

Nah, you misunderstand. You were wasting your life UNTIL that NP called and gave you purpose. That's what all docs do when they're on call, they wilt like a flower until the ER gives them purpose.

Ha! I bet that's what they think .....

Not on the same level of severity but this reminds me of a story my chief resident told me when I was an intern. The night nurse asks him about the patient with cerebral palsy in room such and such. He notes the patient in said room does not have cerebral palsy and is in fact s/p total thyroidectomy. Orders stat calcium and is at the bedside while it gets administered. Patient who was all contracted up visibly relaxes and tells him thank you. Sad that no one noted the change in status but I never forgot to order delayed calcium level for a total thyroid and put some replacement orders in (especially if we were pretty sure we dinged the parathyroids).

What. Wow. As a med student, I saw a guy come back from home with legit Trousseau, Chvostek signs - ical was <0.8 w/ ref nl >4 - but he didn't look that bad.

Good catch.

You guys don't check a PTH in the PACU for every postop total thyroid? I'm used to it being a routine order. If the immediate postop PTH >10-15, the chance of significant hypopara in the next few days is basically nil.

Historically, at my current training institutions, PTH hasn't been universally available or quickly resultable, so the Ca is trended q-whatever attending preference and pending the level and stabilization is replaced as needed. It is becoming more available at most of the local hospitals so more attendings are switching over to the PACU PTH check but it has been a slow process. (Also have standing post thyroid orders for notify physician for [insert signs of neck hematoma and hypocalcemia] and I review the symptoms with patients in preop. )

 

[dpmd]

Ha! I bet that's what they think .....


What. Wow. As a med student, I saw a guy come back from home with legit Trousseau, Chvostek signs - ical was <0.8 w/ ref nl >4 - but he didn't look that bad.



Historically, at my current training institutions, PTH hasn't been universally available or quickly resultable, so the Ca is trended q-whatever attending preference and pending the level and stabilization is replaced as needed. It is becoming more available at most of the local hospitals so more attendings are switching over to the PACU PTH check but it has been a slow process. (Also have standing post thyroid orders for notify physician for [insert signs of neck hematoma and hypocalcemia] and I review the symptoms with patients in preop. )

I've experienced carpopedal spasms myself spontaneously due to hyperventilation and they suck. Not sure why the patient wouldn't have said something about it though.

 

[Chillbo Baggins]

Nurse calling consult for Medicine: "We have a patient on the floor in room such and such who was sitting crossed legged in bed, bent forward, felt a pop and now can't bear weight. They has a bulge at their hip and we think it's dislocated"

Me: (weird story but OK) "what does the xray look like?"

Nurse: "We don't have one"

Me: "..........which side?"

*Order xray, femoral head seated perfectly*

 

[Dr.LeoSpaceman]

Good catch.

You guys don't check a PTH in the PACU for every postop total thyroid? I'm used to it being a routine order. If the immediate postop PTH >10-15, the chance of significant hypopara in the next few days is basically nil.

Our faculty at a high-volume endocrine surgery program didn't check post-op PTH even though it was available. All totals or completions get standing Tums and a morning calcium level.

 

[VincentAdultman]

Nurse calling consult for Medicine: "We have a patient on the floor in room such and such who was sitting crossed legged in bed, bent forward, felt a pop and now can't bear weight. They has a bulge at their hip and we think it's dislocated"

Me: (weird story but OK) "what does the xray look like?"

Nurse: "We don't have one"

Me: "..........which side?"

*Order xray, femoral head seated perfectly*

“We don’t have one.”

Yeah, get used to that...

 

[Pir8DeacDoc]

Our faculty at a high-volume endocrine surgery program didn't check post-op PTH even though it was available. All totals or completions get standing Tums and a morning calcium level.

With some trends towards same day total thyroids post op pacu pth is a nice way to stratify who can go and who should stay.

 

[HighPriest]

With some trends towards same day total thyroids post op pacu pth is a nice way to stratify who can go and who should stay.

I never get them, and I send my otherwise healthy totals home with tums for a week. I always see the PTH as “for me” rather than the patient. If the PTH is too low, they’re likely to have a problem, and I’m going to put them on Calcium and calcitriol (which I do anyway. Where I live, a little extra Vitamin D is definitely not going to be a problem).
If they’re in town, and reliable, I’d still wonder if I shouldn’t just send them home on Calcium even with a low PTH, assuming their preop Ca was normal. If they’re from out of town I’d probably admit them for convenience, I suppose.
If the PTH isn’t low, then maybe (probably) they’ll be ok but that’s less certain at 1 hour. (At least, from everything I’ve read). So I would put them on Tums....
So, I’m any case, I’m not sure how often it would change my management. It would definitely result in delays in discharge (because I have to badger my lab to get a PTH done rapidly even when I’m doing a parathyroid with a sedated patient and an open neck). Maybe I’d put a few less people on tums, but probably not.
No discredit at all to anyone doing it, however. To each their own. And there is predictive value, to be sure.

 

[Radetzky]

Working in the icu

Me: "What's the patients functional status?"

Referring team: "normally fully active and independent!"

Pt: "i get puffed putting my shirt on"

Repeat every week.

 

[HighPriest]

Working in the icu

Me: "What's the patients functional status?"

Referring team: "normally fully active and independent!"

Pt: "i get puffed putting my shirt on"

Repeat every week.

I mean, what kind of shape is the referring team in?

 

[dpmd]

With some trends towards same day total thyroids post op pacu pth is a nice way to stratify who can go and who should stay.

I am such a wimp I stayed like 3 days after my total thyroid because I required so much opioids that then it was hard to walk and pee. It is hard for me to imagine sending someone home the same day.

 

[Matthew9Thirtyfive]

I am such a wimp I stayed like 3 days after my total thyroid because I required so much opioids that then it was hard to walk and pee. It is hard for me to imagine sending someone home the same day.

My mom stayed for 2 days. Would have been really hard for her to go home the same day.

 

[dpmd]

My mom stayed for 2 days. Would have been really hard for her to go home the same day.

Glad I am not the only one with poor pain tolerance. My anesthesiologist was great though. Told them I don't tolerate pain well and also benzos and opiates don't work well on me. Luckily they didn't just figure me for a druggie (being a med student probably helped there) and they hooked me up so I was feeling fine in pacu. My surgeon didn't go with all my suggestions though (I discussed stuff like leaving a catheter with local like an on-q pain pump or similar as well as NSAIDs and muscle relaxers) and just went with vicodin and dilaudid for breakthrough pain which I had a lot of. And ice which did not much for the pain but had the added benefit of feeling like I was being choked whenever they put a fresh pack on. Yippee.

 

[HighPriest]

Almost all of my total thyroids are outpatient. Frankly, only a few ever complain about pain or use all of their pain medications. But, you know, experiences may vary. I keep them if they're in bad shape medically or if they get a concomitant neck dissection. I kept a lady this week who looked like a Macy's parade balloon and had DM, OSA, HTN, COPD, and a bad neck. Big substernal goiter with tracheal deviation, retroesophageal components.

She stayed in house one night and went home with a drain in place. Took it out yesterday. She's doing swimmingly.

 

[dpmd]

Almost all of my total thyroids are outpatient. Frankly, only a few ever complain about pain or use all of their pain medications. But, you know, experiences may vary. I keep them if they're in bad shape medically or if they get a concomitant neck dissection. I kept a lady this week who looked like a Macy's parade balloon and had DM, OSA, HTN, COPD, and a bad neck. Big substernal goiter with tracheal deviation, retroesophageal components.

She stayed in house one night and went home with a drain in place. Took it out yesterday. She's doing swimmingly.

Ah, I did have a neck dissection with tons of positive nodes along with delivering my 6 cm mass.

 

[HighPriest]

Ah, I did have a neck dissection with tons of positive nodes along with delivering my 6 cm mass.

Ah, yeah, well....there's your problem, man. Also, diagnosis plays a role in post op pain. At least I think so, anecdotally. If my patient has a benign biopsy and we're doing the surgery for compressive symptoms, and we're not worried about anything else - they seem to do better post op. If they know they have cancer, it's a harder recovery. I think it's more stressful, you're waiting on path, and of course more surgery to boot.

 

[WinslowPringle]

ED MD: "Gotta gal in muh shop for ya...Middle aged female, belly pain. Mild LFT, Bili elevation. WBC, vitals, lipase normal. Got an ultrasound -rads hasn't read it yet but I think I see stones, no fluid. Will you admit?"
Me: "What's her medical history?"
ED MD: "Well....I mean......She's got a gallbladder full of gallstones. I think it needs to come out."
Me:...............


Made me laugh. A surgery intern who had been promised the next gallbag couldn't have been more enthusiastic or persuasive.....

 

[AsianPersuasion]

NP: Hey, can you come take a look at X pt. I think it's possibly cellulitis...

Me: Uh...that's compartment syndrome.

 

[Synchronous]

Medicine intern: hi I have a consult.... for vascular surgery.... for discolored toes

Me: alright, can you tell me more about the patient?

Medicine Intern: the Attending really wants this consult.

Me: ok but can you tell me more about the patient (Intern doesn’t really know anything)

I go to see the patient, guy has scabs on his left foot where he got a scratch on the top of 3 of his toes and a fungal infection on his right. Palpable DP and PT pulses both feet. After “debridement of the dry exudate” pristine skin is exposed on his left foot (the scabs just fell off). Sign off, Thank you for this riveting consult and allowing me to participate in the care of this patient.

 

[dr zaius]

ED: Hey, got this dude in retention. We put a catheter in but it's just frank blood. Had our most experienced nurse place it [direct quote here]. Started CBI. Need you to come down and take a look. I also got a CT scan. No rads read, but looks OK.

*pull up CT scan before going down to the pit of despair known as the ED* The catheter balloon is fully inflated in the bulbar urethra, bladder is massively distended.

I run down there and the catheter is obviously poorly positioned. The balloon port is down passed the patient's knee, irrigation is running and it's pouring out around the catheter, and the poor guy is writhing around in pain. I pulled the catheter and ended up having to scope another one in. The "most experienced nurse" made a massive false passage. Fortunately I was able to send the patient home.

Afterwards I showed the ED attending and "most experienced nurse" the CT and gently informed them that a malpositioned Foley catheter should be a clinical, and not radiological, diagnosis. The ED normally is very good to us here, but over the last year they have really gone downhill.

 

[HighPriest]

ED: Hey, got this dude in retention. We put a catheter in but it's just frank blood. Had our most experienced nurse place it [direct quote here]. Started CBI. Need you to come down and take a look. I also got a CT scan. No rads read, but looks OK.

*pull up CT scan before going down to the pit of despair known as the ED* The catheter balloon is fully inflated in the bulbar urethra, bladder is massively distended.

I run down there and the catheter is obviously poorly positioned. The balloon port is down passed the patient's knee, irrigation is running and it's pouring out around the catheter, and the poor guy is writhing around in pain. I pulled the catheter and ended up having to scope another one in. The "most experienced nurse" made a massive false passage. Fortunately I was able to send the patient home.

Afterwards I showed the ED attending and "most experienced nurse" the CT and gently informed them that a malpositioned Foley catheter should be a clinical, and not radiological, diagnosis. The ED normally is very good to us here, but over the last year they have really gone downhill.

Sounds like things ballooned out of proportions.

 

[ThoracicGuy]

Sounds like things ballooned out of proportions.

 

[HighPriest]

I'm exactly like that, except I would have left my sunglasses in the van accidentally.

Also, not a ginger. To be perfectly clear.

 

[LucidSplash]

For at least the 10th time in 2 weeks, “pulling clots” is not an indication for a fistulagram. It means your dialysis staff aren’t well trained and they are infiltrating the fistula. Please let me know if you have a real indication to interrogate a fistula.

 

[HighPriest]

I get "pulling clots" a lot too. I tell them to stop putting their fingers up their nose. FYI: they can't. It's a compulsion stronger than the urge to breathe.

 

[Jolie South]

For at least the 10th time in 2 weeks, “pulling clots” is not an indication for a fistulagram. It means your dialysis staff aren’t well trained and they are infiltrating the fistula. Please let me know if you have a real indication to interrogate a fistula.

And Banging thrill. And access duplex with like 2L of flow.

It’s not me, it’s you.

I like when they do it so bad the arm is woody and you have to rest it.

 

[ThoracicGuy]

And Banging thrill. And access duplex with like 2L of flow.

It’s not me, it’s you.

I like when they do it so bad the arm is woody and you have to rest it.

Dialysis nurses must have their own ring in hell.

 

[Jolie South]

Dialysis nurses must have their own ring in hell.

Calling them nurses is being generous. I think they actually have less training than a phlebotomist.

 

[ThoracicGuy]

Calling them nurses is being generous. I think they actually have less training than a phlebotomist.

Well, a phlebotomist actually can draw blood...

 

[mestielest]

Preoperative lumbar hernia. My neurosurgeon colleague called me and said that the patient could not urinate and he was unable to find urethral meatus. I went there and saw a mid-penil, hypospadic, and pin-point urethral meatus. I made a dilation using a mosquito and inserted a 14 fr foley. The patient was a funny elder, I asked him whether he was married or not. He said that he was. I asked about his previous sexual health. He said that he had regular sexual activity. I asked him whether he had a child. He said that he had seven. I questioned our hypospadias repairs that sometimes leads to detrimental consequences.

 

[mikeGR]

Preoperative lumbar hernia. My neurosurgeon colleague called me and said that the patient could not urinate and he was unable to find urethral meatus. I went there and saw a mid-penil, hypospadic, and pin-point urethral meatus. I made a dilation using a mosquito and inserted a 14 fr foley. The patient was a funny elder, I asked him whether he was married or not. He said that he was. I asked about his previous sexual health. He said that he had regular sexual activity. I asked him whether he had a child. He said that he had seven. I questioned our hypospadias repairs that sometimes leads to detrimental consequences.

Did you ask him if his children look like him?

 

[ThoracicGuy]

So I get called the other night for a guy that needs dialysis. He has a temporary line in place. Well, the line can't be used anymore. Why? The dialysis nurse thought the bandage needed to be changed and used scissors to cut the bandage off... along with one of the dialysis ports on the catheter.

 

[mestielest]

Did you ask him if his children look like him?

No. But it would be reasonable

 

[mestielest]

So I get called the other night for a guy that needs dialysis. He has a temporary line in place. Well, the line can't be used anymore. Why? The dialysis nurse thought the bandage needed to be changed and used scissors to cut the bandage off... along with one of the dialysis ports on the catheter.

OMG

 

[BigRedBeta]

Re-consulted to remove a non-tunneled HD line on a kid because the peds team and the dialysis nurses (who normally remove them) AND the peds nurses all felt "uncomfortable" doing so.

I recently found out that my PICU nurses are not allowed to remove HD lines because 8+ years ago, one of our legitimately great RNs pulled an HD line and then for completely unrelated reasons 6 hours later, the patient coded and died. So unbeknownst to me since I joined this group, when an HD cath needs to be pulled, the Surgery PA/NP's come and do it. Institutional memory and inertia are a b****

 

[doyouhaveaflag]

I recently found out that my PICU nurses are not allowed to remove HD lines because 8+ years ago, one of our legitimately great RNs pulled an HD line and then for completely unrelated reasons 6 hours later, the patient coded and died. So unbeknownst to me since I joined this group, when an HD cath needs to be pulled, the Surgery PA/NP's come and do it. Institutional memory and inertia are a b****

Interesting...As an intern I had a patient die the day after I pulled his Cordis line. I wonder if we could make the argument that residents shouldn't be removing lines. (Though his death was likely related to him being POD3 after aortic debranching, I felt really bad after this happened).

At one of our hospitals, residents aren't allowed to place foleys because it was felt the UTI rate was higher with them vs nurses. I'm ok with this outcome.

 

[HighPriest]

At the facility where I trained, it seemed like nurses weren't allowed to place or remove anything that might constitute more work on their part. But I may have been a little bitter.

 

[evilbooyaa]

At the facility where I trained, it seemed like nurses weren't allowed to place or remove anything that might constitute more work on their part. But I may have been a little bitter.

ENT consult for NG tube placement was a common one when you were a resident I'm assuming, especially from non-surgical services (in people without a history of skull fractures or head and neck/thoracic surgery/trauma/whatever)

 

[HighPriest]

ENT consult for NG tube placement was a common one when you were a resident I'm assuming, especially from non-surgical services (in people without a history of skull fractures or head and neck/thoracic surgery/trauma/whatever)

I had more than a few for patients with a "history of septoplasty" in the past. Like, distant pass. I mean, damn dude that should make it easier for you.

 

[ThoracicGuy]

I had more than a few for patients with a "history of septoplasty" in the past. Like, distant pass. I mean, damn dude that should make it easier for you.

Yeah, easier to call you!

 

[HighPriest]

Yeah, easier to call you!

Not possible to make that decision any easier for them, I assure you.

 

[swoopyswoop]

I recently found out that my PICU nurses are not allowed to remove HD lines because 8+ years ago, one of our legitimately great RNs pulled an HD line and then for completely unrelated reasons 6 hours later, the patient coded and died. So unbeknownst to me since I joined this group, when an HD cath needs to be pulled, the Surgery PA/NP's come and do it. Institutional memory and inertia are a b****

The peds intern was very annoyed at me when I told her she would be assisting me in removing the line so she could do so in the future without needing a surgeon present.

 

[dpmd]

The peds intern was very annoyed at me when I told her she would be assisting me in removing the line so she could do so in the future without needing a surgeon present.

Whenever medicine would ask surgery to place a line we would make them at least be at bedside for it but preferably would walk them through it. As juniors we easily got plenty to get signed off to do them independently and walk others through it while they struggled to even get enough to get signed off by graduation which is why they would have to call us at night when the had no one qualified to walk them through it in house. Never got called for a removal in residency though.

 

[WheezyBaby]

Whenever medicine would ask surgery to place a line we would make them at least be at bedside for it but preferably would walk them through it. As juniors we easily got plenty to get signed off to do them independently and walk others through it while they struggled to even get enough to get signed off by graduation which is why they would have to call us at night when the had no one qualified to walk them through it in house. Never got called for a removal in residency though.

You're a saint for doing this. I didn't personally run into that issue, but I was always grateful when my anesthesia colleagues would offer to take some extra time and supervise an emergent overnight tube rather than just take it and get back to their work, which they'd have been well within their right to do

 

[mestielest]

Neurosurgery ICU called for a patient who had undergone angiography and IC aneurysm coiling, postop1, no urine output and hematoglob in USG. I tried to irrigate the foley. I could give fluid but the return was null. The foley was 22 fr. One colleague offered to place a cystostomy. Thank God we did not. We performed cystoscopy and saw a long and narrow bladder. We could not reach the end of the bladder. We performed a cystography and saw that the bladder dome is in the hypochondriac area. CT revealed a femoral pseudo-aneurysm that obstructed the bladder outlet and pushed the bladder up the upper abdomen.