EM case

[LT_Oneal_PAC]

This is a odd case in that it occurs across multiple ED visits.

23 yom presents at 0400 on the morning of a 24 hour shift that you picked up to cover your boss being out of town for ACEP. The patient is known to you as you’ve seen him before a few times for severe anxiety over minimally elevated blood pressures (137 SBP for example) and palpitations. He is only on buspar 10mg BID and no allergies.

Complains of chest “pain” described as tightness, shortness of breath since 2100 the previous evening. Pain is constant, non-radiating, non-pleuritic. It started while resting, but he noted a earlier in the day he did take some pre-work out and worked out hard, trying to get back into shape after a long period of more sedentary life. He did not have any symptoms during exercise. The rest of ROS is unremarkable except incidentally notes a year of dysuria and insomnia the past two weeks with waking at night.

he has seen cardiology for palpitations and finished 30 day event monitor 2 weeks ago that was completely unremarkable.

Exam normal. Cardiac US normal. CBC with mild leukocytosis 11. BMP with no derangement. The HS troponin analyzer has run out of reagent, but back up triage analyzer states <0.05. UA yellow color +3 blood with microscope negative for everything. COVID/flu negative. CXR normal. GC/C PCR order though denies that is possible. Advised PCP follow up within 7 days.

Comes in 2 days later and sees your NP colleague. Note states chest pain, shortness of breath, malaise, fatigue, myalgias, cough, rhinorrhea. Performs the same work up with same results excepts does LFT with AST 1600 and ALT 300, otherwise normal. CRP 1. The UA has 3+ blood and 2+ protein on UA with microscopic negative for cells or casts

gives urology referral for th, outpatient RUQ US, diagnosed with mycoplasma and given script for azithromycin.

sees PCP next day and mostly talks about insomnia, states he thinks he is having reaction to buspar, which is stopped with no replacement. 
 

he comes back to ED the next day to see you again. Complains of insomnia. States has not slept more than 3 hours in a night the past 2 weeks. He has no URI symptoms. 
 

now you take it from here. I will say this, some of his issues are anxiety related. Just have to tease out what

[MediMike]

Alright @LT_Oneal_PACwhat does your bedside thoracic U/S show?

Has homeboy been working out a lot? +Blood w/o RBCs is rhabdo to me.

How's the rest of his chem panel? Renal function aite? Sick exposures?

What exactly is in this pre-workout of his, is it meth? How much is he drinking?

Bilirubin available, direct/indirect?

Bedside echo? What exactly is leading to the insomnia, are we talking anxiety/agitation precluding sleep or an inability to lay flat?

Coags?

My initial "just woke up and opened up PAForum" impression is guy is going zero to hero, taking too many supplements and working out too much leading to rhabdo and associated transaminitis. Insomnia is related to the workout powder.

Bet the dude is getting ripped though.

Edited May 16, 2022 by MediMike

[LT_Oneal_PAC]

1 hour ago, MediMike said:

Alright @LT_Oneal_PACwhat does your bedside thoracic U/S show?

Has homeboy been working out a lot? +Blood w/o RBCs is rhabdo to me.

How's the rest of his chem panel? Renal function aite? Sick exposures?

What exactly is in this pre-workout of his, is it meth? How much is he drinking?

Bilirubin available, direct/indirect?

Bedside echo? What exactly is leading to the insomnia, are we talking anxiety/agitation precluding sleep or an inability to lay flat?

Coags?

My initial "just woke up and opened up PAForum" impression is guy is going zero to hero, taking too many supplements and working out too much leading to rhabdo and associated transaminitis. Insomnia is related to the workout powder.

Bet the dude is getting ripped though.

More to today’s visit, he has chest “warmth.” At this moment he is not experiencing any other symptoms.
 

It was his first exercise session for the last 12 months. His renal function and lytes are completely normal. By normal or unremarkable, I do mean the entire rest of the panel is normal. Not tricking anyone. Total bill normal. They do not auto reflex unless the total bili is abnormal.

he doesn’t know what’s in the pre-work out. He admits to marijuana use, but denies otherwise. Rarely drinks. Looks to be legit kid. No sick contacts.

he has no problem laying flat. He wakes up and shortly after feels chest “pain” and shortness of breath. 
 

Echo normal.

no coags have been performed to this point

[SedRate]

Stress ball. Tell him to take a chill pill.

Any new stressors lately aside from getting jacked? What are his social and family history? 

[ventana]

3+ urine rbc.  Second time with 2+ protein.  AST 16,000 ALT only 300

no cells or casts on micro

insomnia

23 yr old.
 

what type of mycoplasma were they treating?  Was this just a guess or lad finding?

dr google says check rpr vrdl  and maybe from exercise (4:1 ast:alt so have tough time making this fit) 

 

[LT_Oneal_PAC]

31 minutes ago, ventana said:

3+ urine rbc.  Second time with 2+ protein.  AST 16,000 ALT only 300

no cells or casts on micro

insomnia

23 yr old.
 

what type of mycoplasma were they treating?  Was this just a guess or lad finding?

dr google says check rpr vrdl  and maybe from exercise (4:1 ast:alt so have tough time making this fit) 

 

It was a guess. 
 

RPR and VRDL are send outs and will take 3 days to come back.

 

there is a specific test to confirm his diagnosis as well as a few more questions that could lead you directly there.

[MediMike]

2 hours ago, LT_Oneal_PAC said:

It was a guess. 
 

RPR and VRDL are send outs and will take 3 days to come back.

 

there is a specific test to confirm his diagnosis as well as a few more questions that could lead you directly there.

Any episodes of sweating or palpitations/tachycardia? (I know he got worked up recently, have they been increasing in frequency and/or did he experience any of those while undergoing that workup?)

Syncope? Flushing? Tremors? Episodes of hypertension?

Do ya'll send metanephrines in the ED?

[ohiovolffemtp]

What are his vitals?

CPK?

Salicylate & acetaminophen use/levels?  NSAID use for post work-out pain?

Did he ever have mono?

What if anything tends to be adulterating your local cannabis?

[LT_Oneal_PAC]

@MediMike

during the 30 day monitor he triggered it once with NSR during the patient triggered event. He reports many episodes of tachycardia but only ever talks about one event where his watch said 147.

on the first day you saw him he noted some diaphoresis, feeling hot, and laid under a fan after his work out. 
 

no syncope. I honestly didn’t ask about flushing, but guarantee he would say yes. He generally says yes to any question and you have to ask 3 more to realize he doesn’t really lol, but the ROS positives I have listed in previously in posts are true.

we could send metanephrines, but buspar will cause false positive and needs to be off for 2 weeks before sending.

@ohiovolffemtp
lab says there must be a problem with the analyzer, as it’s not giving a result. CK will be send out on Monday (2 days), but you can get it in 3 hours if you call in an ambulance driver to courier it to the next hospital

he did use ibuprofen after his work out, regular OTC dosing. No Tylenol or ASA use.

he is unaware of any mono diagnosis

out local cannabis seems to be untainted, at least I’ve not yet found anything. Besides the occasional meth head, we don’t have much of a drug problem in my county, and most of the meth heads are pretty functional.

[MediMike]

13 hours ago, MediMike said:

 

I seem to have quoted myself and it won't let me delete on mobile, promise you I'm not just being arrogant.

@LT_Oneal_PAClet's do that ED classic of all classics and head to the donut of truth. I'm shooting for a pheo...and suuurrrvvveeeyy SAYS?

 

[mgriffiths]

ancef?

[SedRate]

1 hour ago, MediMike said:

I seem to have quoted myself and it won't let me delete on mobile, promise you I'm not just being arrogant.

@LT_Oneal_PAClet's do that ED classic of all classics and head to the donut of truth. I'm shooting for a pheo...and suuurrrvvveeeyy SAYS?

 

Yep, pheo or rhabdo is my guess

[LT_Oneal_PAC]

So I look all this over and ask him if he ever had any dark urine and reveals that his urine was brown the past few days but starting to lighten up. 
 

asked about the muscle aches  noted in the second ED visit and if he had any weakness. “Oh yeah I couldn’t move my arms past here the day after I saw you” and motions to 45 degree elbow flexion. 
 

I order a BMP and it’s fine. Repeat LFT is AST 1900 and ALT 600. Urine myoglobin ordered, but we don’t have the proper tubes so will have to come back later to give sample. CK is send out so I have it couriered, but so emergent problem here. I let him go with sleep hygiene instructions and trazodone 50mg at night for sleep. 
 

CK comes back 22k 6 days after exercise. 
 

Exertional rhabdomyolysis is the diagnosis. It’s the reason for his transamnitis. AST is very abundant in muscle cells, and to a lesser extent ALT, which is more specific for liver injury. Remember SGOT (now known as AST) use to be a marker for myocardial ischemia. If you’re ALT is >800, be more concerned that rhabdo isn’t the cause of the elevations.
 

as very rapidly noted by @MediMikeand @ohiovolffemtp UA dip for blood without RBC is concerning for myoglobin. The UA said the color was “yellow” on both UAs. When I first saw him I just shrugged my shoulders and assumed they are terrible at reading the dip since they said the color was yellow, no complaint of muscle pain or weakness, no lyte or renal function abnormalities. I just let it slide at 4 in the morning. 
 

Exertional rhabdo is pretty much a benign disease, unlike crush injury or medication induced. It occurs most commonly in those who aren’t very active and are getting back into exercise, or those who are psychotic about exercise. See cult of CrossFit. It has been extensively studied in the military. CK levels as high as 410k have been noted with no adverse outcome. CK levels are seen to be frequently as high as 25k just after physical fitness tests. This is not to say be cavalier and send them all home, but if it is less than 5k you should not care about it and know this people will do very well.

he was placed in observation to trend his CK and make sure it was going the right direction and also for me to verify he what was causing the insomnia. 
 

patient refused the trazodone ordered for sleep. Was noted to be on his phone until midnight, and TV was on all night, which explains his insomnia. 
 

I doubt very seriously he has a pheo. I’ve seen him multiple times for random benign complaints. He has never been tachycardic or had a BP over 140. I looked at his event monitor and literally his heart never went above 105. I’ve never seen such a obviously sedentary heart rate. 
 

I brought up the case because just because A) just because someone is anxious doesn’t mean something isn’t going on. Many times there is, they just have so many complaints it’s hard to tease out what they should actually be worried about. B) the above points about LFTs and rhabdomyolysis, which I think is often forgotten and not taught enough. C) exertional rhabdo isn’t as concerning as other forms of rhabdo
 

 

[MediMike]

Well we had fleshed out the rhabdo early on, I didn't think he was working out enough to have exertion as the etiology (guess he was literally getting ripped huh?) so was looking for some zebras there.

Fun case! Thanks for taking the time man

[ohiovolffemtp]

Definitely was leaning towards rhabdo.  There was a Spartan race in the ATV park near the CAH where I work in Indiana.  Full marathon plus obstacles on a hot humid summer day.  75% of my ED (OK, so 6 of 8 beds), was occupied by patients in rhabdo getting aggressive rehydration.  At least 1 got admitted.  That patient's wife was smarter than he was - she refused to run the race, which was very wise because she has only 1 kidney.

I'm shocked that a CPK is a send-out for you.  Even my place which wasn't great for labs could do that.  My early read that there were problems were when the lab tech kept saying there would be a delay getting results because they had to do repeated dilutions on the sample to get the CPK to result.  Clinically, we used the duck theorem to arrive at the diagnosis: it walked & talked like a duck: the patients were stiff and sore and talked about the event (and how thirsty they were), quacked like a duck: their urine looked like coke, so it was a duck: rhabdo.  Empiric treatment with IVF until urinating frequently is a safe way to start with these folks.  Young(er), otherwise healthy, so risk of fluid overload was low.  Not unlike rehabbing firefighters, which I may have done once or twice.

[LT_Oneal_PAC]

4 minutes ago, ohiovolffemtp said:

Definitely was leaning towards rhabdo.  There was a Spartan race in the ATV park near the CAH where I work in Indiana.  Full marathon plus obstacles on a hot humid summer day.  75% of my ED (OK, so 6 of 8 beds), was occupied by patients in rhabdo getting aggressive rehydration.  At least 1 got admitted.  That patient's wife was smarter than he was - she refused to run the race, which was very wise because she has only 1 kidney.

I'm shocked that a CPK is a send-out for you.  Even my place which wasn't great for labs could do that.  My early read that there were problems were when the lab tech kept saying there would be a delay getting results because they had to do repeated dilutions on the sample to get the CPK to result.  Clinically, we used the duck theorem to arrive at the diagnosis: it walked & talked like a duck: the patients were stiff and sore and talked about the event (and how thirsty they were), quacked like a duck: their urine looked like coke, so it was a duck: rhabdo.  Empiric treatment with IVF until urinating frequently is a safe way to start with these folks.  Young(er), otherwise healthy, so risk of fluid overload was low.  Not unlike rehabbing firefighters, which I may have done once or twice.

It’s not. Lab wasn’t getting a result because she thought the analyzer was broken but I suspect she just hadn’t diluted it enough. 
 

brown urine definitely would have tipped me off or if I had seen him on the second visit with complaints of muscle aches and weakness, but I never saw the urine and was marked as yellow and clear by lab.

[LT_Oneal_PAC]

As an aside, I most definitely had rhabdo when I deployed. I did marine corp martial arts program, which essentially amounted to cross fit with a little grappling sprinkled in. I went to the bathroom and couldn’t get off the toilet LOL. I had to put my arms on the stall wall and push myself into standing position. When I went to sit for 2 days I would literally collapse into the chair because my quads couldn’t eccentric load slowly into a sitting position. I just drank water like sponge and crossed my fingers. 

[sas5814]

Saw so much rhabdo in the military its always on my mind. Last duty station I was in charge of 3 TMCs for basic trainees and AIT students. Lots of folks who were out of shape when they arrived get cooked when they start training.

Now I am older and more jaundiced I was going to ask about disability claims? Any lawyers involved?

[SedRate]

2 hours ago, LT_Oneal_PAC said:

 

patient refused the trazodone ordered for sleep. Was noted to be on his phone until midnight, and TV was on all night, which explains his insomnia.  

I was guessing he was stressing out over a new fling (as a result of getting super ripped) or started a new job, program, etc and hence the lack of proper sleep hygiene and waking up stressed.

[SedRate]

2 hours ago, LT_Oneal_PAC said:

So I look all this over and ask him if he ever had any dark urine and reveals that his urine was brown the past few days but starting to lighten up. 
 

asked about the muscle aches  noted in the second ED visit and if he had any weakness. “Oh yeah I couldn’t move my arms past here the day after I saw you” and motions to 45 degree elbow flexion. 
 

I order a BMP and it’s fine. Repeat LFT is AST 1900 and ALT 600. Urine myoglobin ordered, but we don’t have the proper tubes so will have to come back later to give sample. CK is send out so I have it couriered, but so emergent problem here. I let him go with sleep hygiene instructions and trazodone 50mg at night for sleep. 
 

CK comes back 22k 6 days after exercise. 
 

Exertional rhabdomyolysis is the diagnosis. It’s the reason for his transamnitis. AST is very abundant in muscle cells, and to a lesser extent ALT, which is more specific for liver injury. Remember SGOT (now known as AST) use to be a marker for myocardial ischemia. If you’re ALT is >800, be more concerned that rhabdo isn’t the cause of the elevations.
 

as very rapidly noted by @MediMikeand @ohiovolffemtp UA dip for blood without RBC is concerning for myoglobin. The UA said the color was “yellow” on both UAs. When I first saw him I just shrugged my shoulders and assumed they are terrible at reading the dip since they said the color was yellow, no complaint of muscle pain or weakness, no lyte or renal function abnormalities. I just let it slide at 4 in the morning. 
 

Exertional rhabdo is pretty much a benign disease, unlike crush injury or medication induced. It occurs most commonly in those who aren’t very active and are getting back into exercise, or those who are psychotic about exercise. See cult of CrossFit. It has been extensively studied in the military. CK levels as high as 410k have been noted with no adverse outcome. CK levels are seen to be frequently as high as 25k just after physical fitness tests. This is not to say be cavalier and send them all home, but if it is less than 5k you should not care about it and know this people will do very well.

he was placed in observation to trend his CK and make sure it was going the right direction and also for me to verify he what was causing the insomnia. 
 

patient refused the trazodone ordered for sleep. Was noted to be on his phone until midnight, and TV was on all night, which explains his insomnia. 
 

I doubt very seriously he has a pheo. I’ve seen him multiple times for random benign complaints. He has never been tachycardic or had a BP over 140. I looked at his event monitor and literally his heart never went above 105. I’ve never seen such a obviously sedentary heart rate. 
 

I brought up the case because just because A) just because someone is anxious doesn’t mean something isn’t going on. Many times there is, they just have so many complaints it’s hard to tease out what they should actually be worried about. B) the above points about LFTs and rhabdomyolysis, which I think is often forgotten and not taught enough. C) exertional rhabdo isn’t as concerning as other forms of rhabdo
 

 

The LFTs and new exercise program made me think rhabdo initially -- I see it a lot in our trauma pts. But since this was a special case, I thought maybe you were throwing a curve ball like pheo. Lol

[MedicinePower]

Anyone with an AST like that needs to be in-patient with concurrent additional labs and minimally RUQ US. His UA screams rhabdo. What's his CK? How was this guy discharged? What his is GFR and Cr?

[LT_Oneal_PAC]

1 hour ago, MedicinePower said:

Anyone with an AST like that needs to be in-patient with concurrent additional labs and minimally RUQ US. His UA screams rhabdo. What's his CK? How was this guy discharged? What his is GFR and Cr?

I believe your thinking is a little too black and white.

While I may have gotten a INR level, a non-jaundiced patient with normal bilirubin, AST > ALT, normal ALP, normal albumin, no abdominal or GI complaints, doesn’t necessarily need inpatient. Maybe observation if quick follow up can’t be achieved, which it is easily in my locale. 
 

a UA that is “yellow” and “clear” with positive blood dip and “0-5” red cells does not scream rhabdo in a person with no muscle complaints and normal metabolic panel x 2.

read the rest of the thread for CK. If you read the initial post you saw that it was Norma, but specifically it was Cr 0.88 first visit and 0.81 on the second 2 days later. GFR >90 both times. 
 

I’m eager to hear why you think this is such an egregious breech of the standard of care. How many liver failures and rhabdomyolysis cases have you managed on inpatient?

[sas5814]

The only time we admitted rhabdo cases was when the CK was wildly high with tea colored urine and we needed to hydrate them and watch their kidney function for a short while. Admittedly that was.... 30 years ago and the rules may have changed but generally eliminating the aggravating factor (exercise) and hydrating aggressively got the job done. These were also otherwise healthy young people.

[MedicinePower]

4 hours ago, LT_Oneal_PAC said:

I believe your thinking is a little too black and white.

While I may have gotten a INR level, a non-jaundiced patient with normal bilirubin, AST > ALT, normal ALP, normal albumin, no abdominal or GI complaints, doesn’t necessarily need inpatient. Maybe observation if quick follow up can’t be achieved, which it is easily in my locale. 
 

a UA that is “yellow” and “clear” with positive blood dip and “0-5” red cells does not scream rhabdo in a person with no muscle complaints and normal metabolic panel x 2.

read the rest of the thread for CK. If you read the initial post you saw that it was Norma, but specifically it was Cr 0.88 first visit and 0.81 on the second 2 days later. GFR >90 both times. 
 

I’m eager to hear why you think this is such an egregious breech of the standard of care. How many liver failures and rhabdomyolysis cases have you managed on inpatient?

I work ED and there is absolutely no way we would d/c someone with those LFTs. None.

[LT_Oneal_PAC]

6 minutes ago, MedicinePower said:

I work ED and there is absolutely no way we would d/c someone with those LFTs. None.

That’s not anything objective. There is little chance you’ll make it through an urgent care without a prescription for prednisone and azithromycin for any complaint. Doesn’t make it right. Don’t get me wrong, placement in observation would be fine, but I have literature and evidence to back up all my actions. 
 

now the NP who said it was mycoplasma, can’t defend that.