Moderator EMEDPA Posted July 2, 2013 Moderator Share Posted July 2, 2013 Interesting pt I saw the other day. I suspected the dx but was surprised at its severity. 28 yr old male. generally healthy with no prior pmh, meds, or allergies. no ill contacts. no diarrhea. nonsmoker. no etoh or recreational drugs. presents c/o fatigue with n/v all day. started after a day of surfing. temps here have been in the 90's for several days. VS : stable and afebrile. appears tired but nontoxic. questions? Link to comment Share on other sites More sharing options...
PM2PA Posted July 2, 2013 Share Posted July 2, 2013 12 lead? Sugar? Anything out of the ordinary encountered while surfing? Adequate hydration while being out in the heat? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Author Moderator Share Posted July 2, 2013 12 lead not done initially. when admitted was nl. no strange happenings while surfing. may not have had enough to drink during the day... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Author Moderator Share Posted July 2, 2013 65 views and 1 response? come on folks. take a stab at it. Link to comment Share on other sites More sharing options...
loliz Posted July 2, 2013 Share Posted July 2, 2013 For a 28 year old healthy male to present to ED for fatigue with n/v it has to be more severe than just that (are we talking ED here? I made that leap). So- how severe are the symptoms, why did he pursue emergency care? What did he eat/drink that day? Fever, chills, appetite, weakness? Any other outdoor activity? Any other symptoms? CBC, CMP, UA to start Link to comment Share on other sites More sharing options...
rcdavis Posted July 2, 2013 Share Posted July 2, 2013 Okay then, not much interest. I will start. As the students know, before any reasoned diagnosis can be made, there must first exist a listing of potential diagnoses, a differential diagnosis list. This will be modified, trimmed, expanded as data becomes available in the form of new history, labs, physical exam findings, X-rays, studies, etc. For now, given the data that e has provided, there should be at least 4 highly probable or at least highly possible diagnoses which need to be considered. To stimulate discussion, I will start with one ( which is not the one I think the guy has), HEAT EXHAUSTION/dehydration Now, anyone else have some ideas for an expanded differential? Link to comment Share on other sites More sharing options...
d2305 Posted July 2, 2013 Share Posted July 2, 2013 Rhabdomyolysis s/p heat injury. Link to comment Share on other sites More sharing options...
charle007 Posted July 2, 2013 Share Posted July 2, 2013 Did the patient have any rash or any other physical finding. maybe marine envenomation hyper/hyponatremia ( salt water ingestion or excessive sweating) heat exhaustion Link to comment Share on other sites More sharing options...
charle007 Posted July 2, 2013 Share Posted July 2, 2013 D2305 rhabdo answer is also one I'd like to add, did u guys get a ck on the patient. Link to comment Share on other sites More sharing options...
Just Steve Posted July 2, 2013 Share Posted July 2, 2013 Looks like the ROS and V/S were covered in your presentation. Tired after concurrent days of high temps in a young healthy, active person makes me think 1. Electrolyte imbalance 2. fluid imbalance (Heat stress would fall under those two subsets in my mind) 3. Cardiovascular compromise 4. Toxic exposure which is expanded to include illicit drug use, foul food consumption, or environmental. Because of the recent ocean exposure, there may be a chance of Red Tide exposure or some sort of toxic algae bloom. 5. Sunburn 6. Anemia Physical exam would run top to bottom. Mentation and affect is non toxic but tired. Skin color/turgor? HEENT, I am curious of pupillary reaction, oral mucosa moisture/color, any cracks in the lips? Sunburn? Lymph nodes? How are the lung sound? Heart tones? Belly? Does he appear to be moving all his extremities with ease? DTRs? Distal pulses? Lab wise I would most likely start off simple with a BMP, CBC, and UA. I am expecting to see hypernatremia due to lack of free water intake. Being in the ocean surfing, I would not expect a lot of sweating to drop his sodium levels but dehydration is high on my list. I would also be expecting to see his spec grav in his UA to be fairly high/concentrated/dark yellow to amber with a possible spike in the protein level. I'll stop there and see what we have. Link to comment Share on other sites More sharing options...
d2305 Posted July 2, 2013 Share Posted July 2, 2013 Color of urine? Link to comment Share on other sites More sharing options...
bradtPA Posted July 2, 2013 Share Posted July 2, 2013 Add acute renal failure to the diff dx... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Author Moderator Share Posted July 2, 2013 Color of urine? excellent question: "looks like coca-cola". several folks above have reasoned the correct answer which can be gathered from these labs: UA 3+blood, 3+ protein, sg> 1.030 cmp significant for Cr= 2.5 bun =60 CK >78,000 Physicial exam really not that impressive. not tachy. looks a bit dry as far as mucous membranes, etc. cap. refill fine DX: Acute rhabdomyolysis with acute renal failure secondary to heat exposure, n/v, and dehydration. currently still an inpatient with worsening renal failure. decision will be made today whether or not to initiate dialysis. I'm hoping he pulls through this with intact and functioning kidneys as he is a nice guy who got hit out of the blue with this. Link to comment Share on other sites More sharing options...
rcdavis Posted July 2, 2013 Share Posted July 2, 2013 Another small teaching point, rhabdomyolysis is pathoneumonic when there is lots of occult hematuria ( actually myoglobinuria), and the microscopic shows NO RBCs. If there are RBCs on the microscopic.. Look further, think nephritis of some sort. E, did you alkalinize the urine, hyper hydrate and diurese? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Author Moderator Share Posted July 2, 2013 E, did you alkalinize the urine, hyper hydrate and diurese? I started the process with hydration and got him admitted quickly(actually before the ck even came back- I called the lab and they said it was "high" and they were diluting it to run again-good enough for me) and the hospitalist continued with bicarb infusion, lasix, etc Link to comment Share on other sites More sharing options...
cbrsmurf Posted July 2, 2013 Share Posted July 2, 2013 Another small teaching point, rhabdomyolysis is pathoneumonic when there is lots of occult hematuria ( actually myoglobinuria), and the microscopic shows NO RBCs. If there are RBCs on the microscopic.. Look further, think nephritis of some sort. E, did you alkalinize the urine, hyper hydrate and diurese? "pathognomonic" :D question though, why does urine need to be alkalinized? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Author Moderator Share Posted July 2, 2013 "pathognomonic" :D question though, why does urine need to be alkalinized? http://emedicine.medscape.com/article/982711-treatment Link to comment Share on other sites More sharing options...
cbrsmurf Posted July 2, 2013 Share Posted July 2, 2013 interesting... given the lack of evidence, is it standard management to alkalanize the urine in hospitals? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Author Moderator Share Posted July 2, 2013 interesting... given the lack of evidence, is it standard management to alkalanize the urine in hospitals? yup, at least everywhere I have worked. Link to comment Share on other sites More sharing options...
rcdavis Posted July 2, 2013 Share Posted July 2, 2013 "pathognomonic" ed? Thanks. I have used spelled the word once or twice but on iPad fingers and spell check outrace one another. Link to comment Share on other sites More sharing options...
PM2PA Posted July 2, 2013 Share Posted July 2, 2013 How the hell do you get rhabdomyolysis from a sunburn/heat injury? Link to comment Share on other sites More sharing options...
rcdavis Posted July 2, 2013 Share Posted July 2, 2013 interesting... given the lack of evidence, is it standard management to alkalanize the urine in hospitals? I am not sure there is a lack of evidence. Renalpathophysiology is the same as giving CT IV dye to a patient with boarderline renal insufficiency.. Essentially helps the nephron in clearing the macromolecule. Either way, until there is a study which shows inferiority, I think that it will remain the standard of care.. Link to comment Share on other sites More sharing options...
rcdavis Posted July 2, 2013 Share Posted July 2, 2013 You don't, you get it from swimming out on the board multiple times, from working out in the gym, from playing balinom basketball court in 90 degree weather. You think a surfer just might be working on his abs??? Ya think?? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 2, 2013 Author Moderator Share Posted July 2, 2013 hr drove 2 hrs, drank nothing, exercised in heat for 3-4 hrs, got n/v, kept nothing down, drive home throwing up the whole way and came to see me 5 hrs later having kept down no fluids all day and vomiting up his toenails... Link to comment Share on other sites More sharing options...
PM2PA Posted July 2, 2013 Share Posted July 2, 2013 Always just thought it was from trauma of any sort, would never in 1000 years thought of the heat aspect. Very cool case. Link to comment Share on other sites More sharing options...
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