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Even though he's overall sick sick sick, could this pain to his buttocks just be cause by his trying to get up from the couch and he herniated a disk.

The other question I have is this, is he a bike rider? Did he recently go on a very long bike ride and then not cool down from that bike ride? Did he come straight home and catch the newest episode of CSI and NCIS?

My thoughts are that he is a new onset bike rider or exerciser who overdid the exercise, went straight home, sat on the couch like all of us usually do and now he's screwed.

And on to the second section of my post, I've done a thorough google search for scrotal straightener and Doc I think you're nuts, there's not a single site out there that offers this service. I know you have had it done because you tout it so highly on your private facebook page, so what's the phone number to your private physician who straightened out your scrotum????

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Well his AST/ALT levels make me think alcoholic hepatitis which is linked with acute renal failure, the EKG looks like it has peaked T waves meaning hyperkalemia. I'm still stumped as to why he's having leg/butt pain though.

The patient does not drink. We also know he does not have hyperkalemia based on the labs.

Well, I'm not sure how it makes sense here, but the ECG looks suspicious for Brugada syndrome, and shows a long QT.

I had wondered about CES -- but there's no fecal incontinence / urinary retention / sexual dysfunction reported. However, this could cause renal failure and explain some / most of the symptoms.

He hasn't done anything silly like trying to inject some heroin IM into his glute, instead of IV?

No hx of CA?

Is it lupus?

Why do I feel that the answer will make me fell stupid.

AAA?

Conversion disorder?

Exercise-induced asthma?

spinal abscess?

No injecting anywhere. How does CES cause the lab abnormalities we are seeing? No cancer history. We haven't ruled out lupus yet, Dr. House but he does not have a history of it. Your ambulance has a CT/MRI suite and there is no evidence of AAA, CES or spinal abscess.

Even though he's overall sick sick sick, could this pain to his buttocks just be cause by his trying to get up from the couch and he herniated a disk.

The other question I have is this, is he a bike rider? Did he recently go on a very long bike ride and then not cool down from that bike ride? Did he come straight home and catch the newest episode of CSI and NCIS?

My thoughts are that he is a new onset bike rider or exerciser who overdid the exercise, went straight home, sat on the couch like all of us usually do and now he's screwed.

And on to the second section of my post, I've done a thorough google search for scrotal straightener and Doc I think you're nuts, there's not a single site out there that offers this service. I know you have had it done because you tout it so highly on your private facebook page, so what's the phone number to your private physician who straightened out your scrotum????

No riding of any sort other than the couch you find him on. I thought we agreed not to mention that FB page. I know you are the number one fan but if you keep it up, I may have to shut it down. http://www.dailymail.co.uk/femail/article-2335902/How-George-Clooney-inspired-cosmetic-craze-ball-ironing--sees-wrinkles-removed-know-.html

You guys are doing good so far with this scenario. It was a tough one that was almost missed. It took 2 people at different times to say something that made me put all of the clues together. I will tell you, this is not sciatica. That is what I was initially thinking and was about ready to give this kid some toradol and norflex and send him home. Luckily the triage nurse didn't like the way he looked and the high heart rate so she did the EKG. The initial computer read on the EKG said STEMI. So I was stuck having to justify why the computer was wrong so I ordered a cardiac screen while I waited for the cardiologist to call back. His Troponin-I came back at 6.64 (normal is less than 0.5). So, now you have a young guy with pain out of proportion to exam and signs of multi-system injuries. How do we explain this??? Hint, the answer has already been mentioned.

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I thought I'd weigh in on a potential consideration. A possible consideration is mesenteric ischaemia, possibly venous with this patient.

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That Chris or maybe with my reading up on this that it could be a nasty blood clot to the region. This could be pain caused by the clot. Did we do a US on the vasculature area? I can't recall. High troponins are not always caused by MI's are they? Can the D-dimer be elevated due to the clot in his butt?

Edited by Ruffmeister Paramedic

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Does he have a bite of any sort. Had a pt. not to long ago that became septic from a bite. Don't know what his labs were but same symptom's with the heart rate etc. Or because he does nothing but sit on his ass, how about a blood clot. I have seen some very sore legs with clots.

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Do you employ Nurse Jamie Doc? If so she can straighten my tackle anytime of the day. OF course it's all medically necessary and insurance approved of course.

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I thought I'd weigh in on a potential consideration. A possible consideration is mesenteric ischaemia, possibly venous with this patient.

Mesenteric ischemia comes from arterial occlusion. We have pretty much ruled that out with a normal CT and lactate. The pain will be abdominal and not buttock and thigh (although not everyone reads the textbook).

That Chris or maybe with my reading up on this that it could be a nasty blood clot to the region. This could be pain caused by the clot. Did we do a US on the vasculature area? I can't recall. High troponins are not always caused by MI's are they? Can the D-dimer be elevated due to the clot in his butt?

We did an US that showed no clots. Troponin elevations can be caused by anything that causes damage/stress to the heart. It can also be elevated in renal failure/insufficiency because it is cleared by the kidneys. D-dimers can be elevated due to anything that causes an inflammatory response in the body. They are very non-specific.

Does he have a bite of any sort. Had a pt. not to long ago that became septic from a bite. Don't know what his labs were but same symptom's with the heart rate etc. Or because he does nothing but sit on his ass, how about a blood clot. I have seen some very sore legs with clots.

No bites.

Do you employ Nurse Jamie Doc? If so she can straighten my tackle anytime of the day. OF course it's all medically necessary and insurance approved of course.

Yes, I hired nurse Jamie but we had to let her go due to reasons we are not allowed to discuss.

Sexy-Brain-Eating-Zombie-Nurse1.jpg

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OK : going back to his IV drug use.

When he was shooting up ,Where was he injecting?

Necrosis from injecting in his lower extremity??

Venous infection causing the cardiac issues?

Myocardium inflammation?

The pain in the butt is throwing a curveball here doc ???????

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NF is another potential life threat to consider.

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Your astute NP looks at the labs and hears the story and asks you what the CPK is.

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