Case history
Case history #1
A 38-year-old male is brought into the accident and emergency department following a motorcycle crash. He is splinted after sustaining a closed left tibial plateau fracture with left mid-shaft tibia and fibula fractures. Along with his resuscitation, he is admitted with plans to go to the operating theatre the next morning for surgical repair. He complains of excruciating pain in his left leg and receives a dose of fentanyl. He requests a second dose of fentanyl an hour later, which the nurse administers. The nurse receives orders to deliver a moderate dose of hydromorphone to be repeated every 4 hours as required. The following morning the patient no longer complains of pain, but he can no longer feel his left leg.
Case history #2
A 23-year-old male presents to the accident and emergency department after experiencing worsening back pain for 3 days. He had been training in an extreme work-out session for endurance enhancement and bodybuilding, and also admits to using muscle protein supplements for the previous 2 months. He has taken 3 ibuprofen 800 mg tablets in the past 3 days with no improvement in pain. He has developed generalised fatigue and malaise. He notes his urine to be tea-coloured and reports a gradually decreasing urine output.
Other presentations
Unlike traumatic presentations, medical presentations of rhabdomyolysis are often subtle and must be suspected given the appropriate clinical setting. The patient may be without symptoms or may have vague complaints of increased fatigue or generalised malaise. Rather than complaining of muscular discomfort, the patient with drug use or an infection may present with dark-coloured urine or oedema of the limbs. In one general review, only 50% of patients complained of muscular symptoms, and physical findings of rhabdomyolysis were present in only 4% on admission.[3] Unless the diagnosis is suspected and specific laboratory evidence is obtained, rhabdomyolysis may not be diagnosed until complications ensue.
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