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My back hurts

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Doppler U/S? VS? How is his mental status/respiratory effort?

Is the one leg bigger/redder/warmer than the other?

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US shows no DVT. He is A&OX3 and in no resp distress. There is no visible asymmetry in the legs.

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Any s/s renal disease? I suppose pain could be radiating down to the butt from the flank? BUN/Creatinine?

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Well the reference range for BUN I learned is 6-20 and Cr 0.6-1.2...I'm thinking some renal failure is going on for some reason or another...has he recently started working out? Any chance this could be rhabdo?

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Nope, no recent exercise, other than getting up to grab the remote.

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Shucks... was just reading on renal failure and saw it can cause an increase in a D-dimer as well.

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did he fall asleep on the couch in mommy's basement with the remote underneath his butt?

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Ok. Let's review a bit.

We have an 18 YOM complaining of back pain for two days now. It hurts him to stand on it or sit on it.

Do we have his PMH including meds, allergies, history of smoking, drinking, drug use?

Can we please get a set of vitals?

On exam he's pale and sweaty without any signs of infection or trauma to the skin/extremity.

Lung sounds?

Heart sounds?

Abdominal pain on exam?

Back exam reveals no CVA tenderness.

Extremity exam reveals severe pain on palpation with a refusal to even move the affected leg. Bilat distal pulses present. No visible differences between bilat LE.

Neuro exam appears intact. Bowel/bladder incontinence?

Labs (Hey! We have labs in the field!) show protein and blood in his urine, renal failure (BUN/CREAT are elevated), an elevated D-dimer (from the renal failure or from something else? Hmmm...), negative extremity U/S for DVT.

Let's get this guy on the monitor. I would hope we started a line to draw the blood so let's hang some fluid. Load him up on some pain meds and roll.

Since we already have some values do we also have the CBC and the rest of the chem?

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did he fall asleep on the couch in mommy's basement with the remote underneath his butt?

No remote is found upon inspection of the buttocks.

Ok. Let's review a bit.

We have an 18 YOM complaining of back pain for two days now. It hurts him to stand on it or sit on it.

Do we have his PMH including meds, allergies, history of smoking, drinking, drug use?

Can we please get a set of vitals?

On exam he's pale and sweaty without any signs of infection or trauma to the skin/extremity.

Lung sounds?

Heart sounds?

Abdominal pain on exam?

Back exam reveals no CVA tenderness.

Extremity exam reveals severe pain on palpation with a refusal to even move the affected leg. Bilat distal pulses present. No visible differences between bilat LE.

Neuro exam appears intact. Bowel/bladder incontinence?

Labs (Hey! We have labs in the field!) show protein and blood in his urine, renal failure (BUN/CREAT are elevated), an elevated D-dimer (from the renal failure or from something else? Hmmm...), negative extremity U/S for DVT.

Let's get this guy on the monitor. I would hope we started a line to draw the blood so let's hang some fluid. Load him up on some pain meds and roll.

Since we already have some values do we also have the CBC and the rest of the chem?

He has a past medical history of Ultram induced seizures about 4 years ago. Otherwise, no history or meds. He smoke 0.5ppd, no alcohol use. He has a history of heroin abuse, he last shot up over 3 months ago. He smoked some marijuana a few days ago.

Vitals: P 112, BP 157/99, RR 18, Temp 36.9 orally, 99% on room air

Lungs are clear bilat

Heart RRR, nl S1, S2, no murmur, rubs or gallops.

Abd is soft, non-tender, non-distended

No bowel or bladder incontinence

Na 132

K4.4

Cl 96

Bicarb 24

Anion Gap 12

BUN 36

Cr 2.3 (These are the correct values, the previous ones were my incorrect recollection)

Glucose 108

Ca 8.8

Mg 2.6

Phos 5.2

Total protein 8

Albumin 4

Total Bili 0.7

Alk Phos 66

AST 907

ALT 362

WBC 16.19

Hgb 16.7

Hct 46.4

Plt 225

Red denotes abnormal lab values in our system.

I don't have a rhythm strip, but I'll give you the 12-lead

EKG_zps06c1ec30.jpg

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