Mr. Cooper is a 26-year-old man who is seen in Provider Sick Call as a follow-up to an emergency department visit yesterday where he was seen for almost collapsing while fighting a fire. He is part of the Department of Correction’s specialized fire squad working the out-of-control forest fires up north.
He was in full gear and fighting fires all day – “non-stop” from early in the morning. He states he tried to stay hydrated and drank a lot of water during the day, but started feeling “lightheaded and woozy” and he asked to take a break.
They were cutting a fire line that required rigorous digging, shoveling, and cutting brush. After taking a short 15-minute break, he resumed his usual duties, only to sit out again roughly 20 minutes later due to severe muscle pain in his calves and shoulders. He tried to continue, but the pain was too severe. He informed his officer, who transported him to the local Emergency Department for evaluation. The local Emergency Department evaluated Mr. Cooper and informed him his dark urine was an indication that he was dehydrated, and he was released with the instructions to drink fluids.
Today Mr. Cooper states that he continues to have dark colored urine, and he is in great pain, which is mostly in his shoulders. Overall, he describes feeling like he has been “hit by a Mack truck.”
Review of Systems
Mr. Cooper’s Review of Systems is positive for weakness and exhaustion; palpitations; shortness of breath; nausea; dark-colored urine; and muscle pain in his shoulders, lower back, and calves. His Review of Systems is negative for diarrhea, constipation, anuria, hematuria, muscle weakness, numbness, or tingling.
Mr. Cooper reports no medication or food allergies, and he currently takes no medication.
Vitals: : T 99.1°F, P 96, R 12, BP 134/86, HT 6’1″, WT 225 lbs – BMI 29.7.1.
General: A&O; no acute distress. Overweight.
Skin, Hair, and Nails: No erythema or pallor of skin noted. Hair and nails unremarkable.
Head: Atraumatic, normocephalic.
ENT/Mouth: Mucous membranes moist and pink.
Neck: Supple; no masses; normal thyroid; no jugular vein distension.
Lungs: Vesicular breath sounds diffusely. Breath sounds were equal throughout.
Heart: S1 S2, RRR; no murmurs, rubs, or gallops; nondisplaced PMI. Capillary refill less than 2 seconds.
Abdomen: Soft; mild epigastric tenderness; no costovertebral angle tenderness; no splenomegaly; no hepatomegaly. Tenderness with palpation generalized over bilateral flanks. Normoactive bowel sounds all quadrants.
Musculoskeletal: Generalized tenderness to palpation over bilateral shoulders. Limited Range of Motion of shoulders bilaterally due to pain. Generalized tenderness over calves and quadriceps bilaterally. There is severe pain with palpation over the paralumbar musculature with voluntary guarding and hypertonicity.
Neurology: Alert and oriented ×4. Cranial nerves II to XII intact.
Correctional Nurse Actions
Prepare Mr. Cooper for the Provider evaluation and ensure that the paper work from the Emergency Department is available for review (not just the discharge summary, but the Provider and Nursing notes). When ordered, obtain labs STAT and monitor to ensure that the results are shared with the Provider as soon as they are sent to the facility.
Differential Diagnoses for MR. Santiago
Dehydration is a possible diagnosis. Certainly, the patient has a good cause for dehydration, given he was working vigorously in intensely hot conditions. In addition, patients often are fatigued when dehydrated. However, dehydration alone would not explain the severe muscle pain.
Musculoskeletal injury (shoulder, knees, back) is also a possible diagnosis. The patient has a history of injuries and musculoskeletal pain. However, this does not explain his fatigue or dark-colored urine, and simultaneous multiple musculoskeletal strain or sprain is unusual.
Rhabdomyolysis is a likely diagnosis. It often presents with muscle pain, weakness, and dark urine. Patients are often fatigued and in pain. This patient’s clinical presentation is very consistent with these symptoms. Further testing is required to make the diagnosis.
Polymyositis should be considered. The chief characteristic of this syndrome is progressive muscle weakness. It does not normally present with an abrupt onset of muscular pain. Also, dark urine does not support this diagnosis.
Myofascial pain syndrome is a possibility given the patient’s history of shoulder pain. This syndrome is more common in the elderly and not associated with acute fatigue or dark urine. It is also strongly associated with palpation of nodules or tight bands of musculoskeletal tissue, which is absent in this case.
Most Likely Diagnosis: Rhabdomyolysis
Rhabdomyolysis is the result of skeletal muscle necrosis caused by inadequate oxygenation to a muscle group. Most commonly it is a result of extreme overwork, direct trauma, crush injuries, or compartment syndromes. Cellular breakdown of muscle results in elevated potassium, phosphate, calcium, and cellular proteins, most notably CK. Another consequence of cellular degradation leads to an excess of free Hgb in the bloodstream, which is further cellularly degraded into their subunits, myoglobin. This results in the characteristic finding of dark (“tea-colored”) urine. Myoglobin is filtered through the kidney and is nephrotoxic. If untreated, it can lead to acute renal injury.
UA dip to further evaluate dark-colored urine patient was describing
STAT Chemistry panel to evaluate electrolyte and kidney functions
STAT CBC to rule out infection
STAT CK to evaluate muscle pain
That evening, the laboratory called to inform the facility of a critical lab result.
UA dip: Significant for clear brownish color; trace leukocytes, negative nitrates, + blood, + protein
Chemistry panel: Na: 138; K: 4.8; Cl: 108; HCO3: 22; BUN: 22; Cr: 1.4; glucose 102
CBC: WBC 11.2; Hb 13.2; HCT: 39.4; platelet 389
CK: 11,284 U/L (normal range 30–135)
The patient’s CK level was 11,284 – a significant elevation. The Provider was notified, and Mr. Cooper was sent urgently to the Emergency Department. After his evaluation and diagnosis of Rhabdomyolysis, Mr. Cooper was admitted to the hospital. He was treated with IV fluids and subsequently oral hydration. He had a dramatic response; he had resolution of his hematuria and improvement of his subjective shoulder and leg and back pain. He was followed up with serial CK levels, chemistry panels, and urine samples specifically at Days 2, 3, and 7 following his initial presentation.
He returned to the facility on day 4 and continued to be treated by the facility provider. Over the course of treatment his symptoms completely resolved, and his laboratory findings normalized. Luckily, he did not experience acute renal failure, other organ failure, or any other major complication.
Renal failure develops in up to 46% of patients with rhabdomyolysis. This is a common complication and warrants close follow-up.
Pigmented casts on urinalysis are indicative of rhabdomyolysis acute renal failure.
Cellular breakdown of muscle results in elevated potassium, phosphate, calcium, and cellular proteins, most notably CK. Another consequence of cellular degradation leads to an excess of free Hgb in the bloodstream, which is further cellularly degraded into their subunits, myoglobin. This results in the characteristic finding of dark (“tea-colored”) urine. Myoglobin is filtered through the kidney and is nephrotoxic and if untreated can lead to acute renal injury. Many factors can cause rhabdomyolysis, but direct muscle injury is the most common.
What is rhabdomyolysis?
Signs and symptoms of rhabdomyolysis
Causes of rhabdomyolysis
Rhabdomyolysis should be suspected in individuals presenting with a history of multi-trauma, crush injuries, or moderate to severe physical exertion. It can often present as severe muscle pain, cramping, and stiffness, but it is notable that more than half of the patients may not report any muscular complaints at all. It can also be a result of autoimmune injury, alcoholism, hypothermia, drug abuse, medication adverse effects, and various other clinical conditions that affect muscle cellular metabolism. In the correctional environment, we often see these patients after engaging in extreme physical exercise.
It is imperative that a thorough Review of Systems is performed with patients presenting with extreme exhaustion or dehydration, as severe cases can rapidly progress to acute renal injuries and cardiac injuries, even in the absence of musculoskeletal complaints.
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Cervellin, G., Comelli, I., Benatti, M., et al. (2017). Non-traumatic rhabdomyolysis: background, laboratory features, and acute clinical management, Clinical Biochemistry. 50(12):656–662. doi:10.1016/j.clinbiochem.2017.02.016
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Wijesinghe, Sampath. (2021). 101 Primary Care Case Studies: A workbook for clinical and bedside skills. Springer Publishing Company. Kindle edition.
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