Ms. BZ is a 63 year old female with chief complaint of body ache and dark colored urine x 3 days.

History elements (these also indicate the questions that should be asked)

• • POD 5: Healing from right hip replacement in hospital. Hip replacement was needed due to arthritis of hip joint. Operation was a success with no complications throughout procedure. Patient is on Codeine for post-op pain; denies side effects.
  • Admits to muscle pain and cramping at shoulders and upper to mid-back, subjective fever, weakness, fatigue and palpitations. Notices that her urinary output is less today than the past 2 days.
  • Denies chills, nausea, vomiting, diarrhea, weight loss, strenuous activity, falls, seizures, nor other symptoms.
  • PMH: Hypertension, Hyperlipidemia
  • Social history: patient is retired and lives with wife, non-smoker, never illicit drugs, non-drinker
  • Family history: mother and father has hypertension, died of old age
  • Medications: Codeine 15mg (for post-op pain), Lisinopril 40mg, Atorvastatin 80mg, Multivitamins
  • Allergies: NKDA, no food allergies

Physical Exam (also indicates what procedures should be done)

• • Vital signs – Temp 100.2°F, Pulse 110bpm, BP 130/82, RR 20, BMI 28
  • Gen – appears fatigued, slightly disheveled in grooming and dress, NAD
  • Skin – Well-healing scars noted around right hip from surgery. Redness and tenderness noted at upper to mid-back and shoulders; no open wound/lesions noted.
  • Abdominal – BS present in all quadrants, non-tender to palpation throughout, negative special tests (ie: CVAT)
  • Musculoskeletal – no atrophy of muscles noted; 5/5 muscle strength bilaterally, PROM and AROM
  • All other systems WNL.

Differential Diagnosis (explain WHY)

• • Rhabdomyolysis – from muscle breakdown due to immobility post-surgery; patient has the classic triad of muscle pain, muscle weakness, and dark colored urine; statin is a risk factor for this condition
  • Acute kidney injury – dark colored urine, less urine production, AKI may have been caused by prolonged rhabdomyolysis
  • UTI – dark colored urine
  • Nephrolithiasis – dark colored urine, less urine production, back pain

Tests (Student will be given results for any that are ordered):

• • CMP: Sodium 140, Potassium 6.0, Calcium 7.5mg/dL, Creatine 1.6mg/dL, BUN 22mg/dL
  • CBC: WBC 15k, Hb 18g/dL, Hct 52%
  • Creatine kinase: 25,000U/L
  • Elevated ESR, CRP, AST, ALT, LDH
  • Urinalysis – color: dark brown, clarity: clear, specific gravity: 1.010, pH 6.0, bilirubin: negative, ketone: negative, blood: positive, protein: negative, nitrite: negative, leukocyte esterase: negative, WBC: negative
  • Urine culture – negative
  • Microscopic analysis of urine – positive heme, negative RBCs
  • EKG – slightly peaked T waves

Treatment

• • IV NS, with target urine output: 0.5-1.0mL/kg/hr
  • For hyperkalemia: Albuterol, Bicarbonate (if acidotic to alkalinize urine), Calcium gluconate, Dextrose, Insulin, consider Mannitol to have patient flush out excess potassium
  • Consider switching patient to a different lipid-lowering agent

Pt. counseling

• • Encourage fluid-intake, and reporting if there is decreased urine production noted
  • Educate patient on the possible cause of her condition (ie: inactivity, statin-use), and what signs to look out for
  • Counsel about the need for early ambulation post-surgery
  • Inquire if patient has any further questions

Source:

• • https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-rhabdomyolysis?search=rhabdomyolysis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
  • PANCE Pearls Volume 3
  • Emergency Medicine: Urology disorder slides