A 22-Year-Old Man in Pain After Collapsing

Faizah Siddique, MD; Herbert S. Diamond, MD

Disclosures

March 18, 2019

Physical Examination and Workup

The patient is examined in the emergency department approximately 1 hour after the episode. His vital signs include a temperature of 99.5°F, a blood pressure of 116/74 mm Hg, and a heart rate of 110 beats/min. His weight is 250 lb, and his height is 6 feet 2 inches. He is a muscular, but obese, young man in no discomfort. He has a regular heart rhythm, and no murmurs or bruits are auscultated.

The patient's lung and abdominal examination findings are normal. His cranial nerves are intact. His proximal upper-extremity muscle examination reveals bulky muscles with 4/5 strength; the remainder of his examination findings are normal. His muscles are tender and doughy. He has normal sensation to light touch, pinprick, cold, and vibration. His deep tendon reflexes are 2+. Finger-to-nose test findings are normal. The Romberg sign is negative. His gait is normal. His neuromuscular examination findings are otherwise normal.

Initial laboratory test results reveal a hemoglobin level of 14.5 g/dL, a hematocrit of 49%, and a white blood cell count of 11,200, with 72% neutrophils and no bands. A renal electrolyte panel reveals a creatinine level of 1.7 mg/dL, a sodium level of 135 mmol/L, and a potassium level of 4.9 mmol/L. His creatinine phosphokinase level is 12,976 IU/L. The remainder of his basic metabolic panel findings, including calcium, magnesium, and phosphorus levels, are normal.

The urinalysis is positive for blood, but no red cells are found. Urine drug screen results are negative. The patient's urine is dark (Figure).

Figure.

CT of the head and MRI of the brain are both normal. An ECG is notable for sinus tachycardia. The EEG findings are normal. Electromyography and nerve conduction study findings are normal.

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