Check out the first COtM of 2016 and get your brains kick-started in the new year:
A 42 year-old man presents to the emergency department with persistent leg pain, vomiting, shortness of breath and tea-colored urine. One week prior to admission, he began to experience diffuse pain in the back and his legs. The pains persisted as a dull aching sensation that worsened with activity. There is no history of trauma or heavy physical exertion. The patient denies having fever, fatigue, weakness, or weight loss. There are no toxin or chemical exposures.
PMH: None
PSH: Denies
Meds: No prescribed or over-the-counter medications. No herbal remedies.
All: NKDA, no other allergies
SH: No tobacco use, social EtOH consumption (about 3-4 beers each weekend). Sexually active with the same woman for the past 8 months. Works as a sales executive.
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Physical examination:
Vitals – 120/72, HR 89, temp 99.1F, RR 21, 98% on RA
HEENT – Unremarkable
CV – S1S2, RRR, no m/r/g
Resp – CTA b/l, no w/r/r
Abd – soft, nt, nd, +BS
Ext – bilateral inguinal lymphadenopathy and pedal edema. No LE tenderness.
Neuro – 5/5 strength in all extremities, no sensory deficits, normal LE and UE reflexes, CN II-XII intact, normal cerebellar exam
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Labs:
CBC – WNL
CMP – 140/4.7/104/18/31/6.8<121 Ca 7, Mg 2.1, Phos 10 Tprot 10, Alb 3.9, AST 3640, ALT 419, Alk phos 120, Bili 0.6.
UA – Hgb positive, 4+ proteinuria; microscopy revealed numerous granular casts, no epithelial cells, and no RBCs.
CK – 278,000.
Utox – Negative
The remainder of the labs were WNL
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EKG: NSR, no ST segment changes, no peaked T-waves
CXR: No acute process
Bedside Sono: No hydronephrosis
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So what’s going on here? What is the cause of the patient’s symptoms and lab abnormalities? Respond with your differential diagnosis, further testing, and your initial therapeutic management. The best overall post wins the prize for January. Crunch those brains!
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4th Year EM-IM Resident at SUNY Downstate/Kings County Hospital
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2 Comments
Sarah · January 11, 2016 at 11:25 pm
DDx: Leptospirosis, APAP toxicity
Send cultures.
APAP levels.
Get more history from patient – pets/animals? travel history? exposure to bodies of water?
Tx:
doxycycline IV 100mg q 12h – monitor WBC, fevers, f/up cultures
IV fluids – monitor SCr, UOP, CXR, O2sat, LFT’s
if APAP tox suspected, start IV NAC 150mg/kg x 1hr + 50mg/kg x 4 hrs + 100mg/kg x 16hrs – f/up APAP levels, LFT’s
Brian · January 11, 2016 at 11:47 pm
It appears that the patient is in rhabdomyolysis which likely caused his renal failure. The question is what caused the rhabdomyolysis.
Ddx includes Mono, Legionella (is he from the Bronx?), Influenza, Mono, Glycogen storage disorders and viral hepatitis (most likely).
Immediate tx with aggressive fluid hydration while specific lab tests are sent off.