More Than Meets the Eye

A 61-year-old woman was hospitalized with a 2-day history of palpitations and dyspnea. She was found to be in atrial fibrillation with a rapid ventricular response, and intravenous diltiazem and a heparin infusion were begun. Her condition improved, but on the third hospital day, she reported feeling weak and nauseated and began passing dark red urine. She did not have a urinary catheter, palpitations, dyspnea, back pain, abdominal pain, dysuria, or dizziness. A 61-year-old woman was hospitalized with a 2-day history of palpitations and dyspnea. She was found to be in atrial fibrillation. With treatment, her condition improved, but on the third hospital day, she reported feeling weak and began passing dark red urine. Foreword In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows. Stage A 61-year-old woman was hospitalized with a two-day history of palpitations and dyspnea. She was found to be in atrial fibrillation with a rapid ventricular response, and intravenous diltiazem and a heparin infusion were begun. Her condition improved, but on the third hospital day, she reported feeling weak and nauseated and began passing dark red urine. She did not have a urinary catheter, palpitations, dyspnea, back pain, abdominal pain, dysuria, or dizziness. Response The presence of dark red urine usually suggests either gross hematuria or pigmenturia (hemoglobinuria or myoglobinuria). Although pigmenturia is commonly manifested by cola- or tea-colored urine, . . .