Case Of the Month 7 – Presentation

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!