MDM - Rhabdomyolysis (Admit)

[##]-year-old [male/female] with [back pain/dark/bloody urine/etc.] with history and exam consistent with rhabdomyolysis.

Initial consideration in this patient included rhabdomyolysis, acute kidney injury (AKI), hematuria from causes including kidney or ureteral stone, urinary tract infection (UTI), pyelonephritis, or malignancy, glomerulonephritis, musculoskeletal etiologies of back pain, cauda equina syndrome, intervertebral disc herniation, and change in urine color from foods such as beets, blackberries, rhubarb, food coloring, or fava beans among others. 

Patient presented with report of [back pain/change in urine color] concerning for rhabdomyolysis.  We obtained a urinalysis that was notable for being [grossly/moderately] positive for blood with [no/minimal] red blood cells noted on microscopic analysis.  Patient reports [describe recent exertion] within [12-72 hours/1-2 days] of presentation.  Labs were obtained to include a creatinine kinase (CK), which was noted to be [moderately/significantly] elevated.  Patient noted to have [no] evidence of hyperkalemia [specify].  A 12-lead EKG was obtained [and noted to be unremarkable/and notable for evidence of peaked T waves suggestive of hyperkalemia].  Patient noted to have [no] evidence of AKI [based on increase in creatinine from baseline/with an AKIN score/RIFLE classification of RIFLE-R/I/F/FO].

Patient treated with normal saline IV [with 1-2 liter bolus followed by an infusion at 2.5 mL/kg/hour] while monitoring urine output.  Patient felt to require admission based on [comorbdities/associated trauma/heat injury/associated kidney injury/consider admission in patient with CK >30,000].  Case discussed with Dr. [Name of Internal Medicine/the admitting hospitalist] who evaluated the patient in the ED and agreed with need for admission.  We discussed planned admission and treatment plan with the patient who demonstrated understanding and agreement with this plan.

http://www.emdocs.net/emdocs-cases-evidence-based-recommendations-for-rhabdomyolysis/
https://www.mdcalc.com/akin-classification-acute-kidney-injury-aki
https://www.mdcalc.com/rifle-criteria-acute-kidney-injury-aki#evidence

MDM - Rhabdomyolysis (Discharge)

[##]-year-old [male/female] with [back pain/dark/bloody urine/etc.] with history and exam consistent with rhabdomyolysis.

Initial consideration in this patient included rhabdomyolysis, acute kidney injury (AKI), hematuria from causes including kidney or ureteral stone, urinary tract infection (UTI), pyelonephritis, or malignancy, glomerulonephritis, musculoskeletal etiologies of back pain, cauda equina syndrome, intervertebral disc herniation, and change in urine color from foods such as beets, blackberries, rhubarb, food coloring, or fava beans among others. 

Patient presented with report of [back pain/change in urine color] concerning for rhabdomyolysis.  We obtained a urinalysis that was notable for being [grossly/moderately] positive for blood with [no/minimal] red blood cells noted on microscopic analysis.  Patient reports [describe recent exertion] within [12-72 hours/1-2 days] of presentation.  Labs were obtained to include a creatinine kinase (CK), which was noted to be [moderately/significantly] elevated.  Patient noted to have no significant evidence of hyperkalemia on labs [with an unremarkable EKG].  Patient noted to have no other evidence of significant electrolyte abnormalities on labs [look for hypophosphatemia, hypocalcemia, and hyperuricemia].  Patient noted ton have no evidence of associated AKI.

Patient treated with normal saline IV [with 1-2 liter bolus] given in ED in patient noted to be tolerating fluids by mouth prior to discharge.  Patient felt to be appropriate for outpatient management given likely exertional rhabdomyolysis and absence of associated comorbidities [including heat stress, dehydration, crush injury, trauma], electrolyte abnormalities, or renal failure [consider admission in patient with CK >30,000].  Prior to discharge we discussed the importance of increased intake of fluids, rest and avoidance of further exertion, and follow up with [primary care provider/here in this ED] for repeat CK to ensure this is downtrending within [24/48/72 hours].  We also discussed return precautions, specifically for evidence of renal failure, and the patient demonstrated understanding and agreement with this plan.

http://www.emdocs.net/emdocs-cases-evidence-based-recommendations-for-rhabdomyolysis/

Discharge Instructions - Rhabdomyolysis

As discussed in the Emergency Department prior to discharge, you have been diagnosed with rhabdomyolysis.  Rhabdomyolysis is when muscle tissue gets severely damaged and substances from inside the muscle cells leak out into the blood.  This can lead to more serious problems including kidney damage and electrolyte disturbances that can result in deadly irregular heart rhythms.

Different things can cause the muscle damage associated with rhabdomyolysis including muscle injury or surgery, very intense exercise, lying in the same position for a very long time, certain infections, medications and poisons, and certain hereditary muscle disorders.

Rhabdomyolysis can cause muscle pain, red or brown discoloration of the urine, and muscle weakness.  Treatment depends on the cause and severity of rhabdomyolysis.  You may have received fluids through an IV in the Emergency Department, which can help your body flush out the harmful substances released from muscle cells.  It is important that you drink plenty of fluids in the next 24-48 hours to continue to flush out harmful substances in the blood.

You may have been directed to follow up with your primary care provider or in the Emergency Department for repeat labs.  It is important that you follow up with these labs to ensure that your kidneys are recovering from rhabdomyolysis.

Return to the Emergency Department for worsening pain, fever (≥38.0 °C or 100.4 °F) after 2 days of antibiotics, inability to pass urine for 6 hours after multiple attempts, or any new or concerning symptoms.

Discharge Instructions - Groin Strain

As discussed in the Emergency Department prior to discharge, you have been diagnosed with a groin strain.  A groin strain happens when one of the muscles in the inner thigh gets stretched too much or too quickly, or works too hard.  This sometimes makes the muscle tear.  This is sometimes also called a “pulled groin.”

A groin strain can happen while exercising, such as from suddenly changing direction or during an accident.  The muscles involved in a groin strain are called the adductor muscles, which connect the groin muscles to the thigh and pull the legs toward each other.

A groin strain is the most common cause of groin pain, especially in active adults.  It can be mild or severe.  Treatment involves resting the muscles of the groin and avoiding activities that cause pain.  You can ice the area for about 10 minutes, and then remove the ice for several minutes to prevent frostbite.  You can take Acetaminophen (also known as Tylenol) or Ibuprofen (also known as Advil or Motrin) for the pain.

Return to the Emergency Department for worsening pain, testicular pain or mass, fever (≥38.0 °C or 100.4 °F), or any new or concerning symptoms.

MDM - Musculoskeletal Back Pain

[##]-year-old [male/female] with back pain with history and exam consistent with likely musculoskeletal back pain.

Initial consideration in this patient included herniated intervertebral disc, acute ligamentous injury, acute muscle strain, spondylolisthesis and other musculoskeletal etiologies, cauda equina, spinal fracture, spinal stenosis, epidural abscess and hematoma, cancer metastases, and kidney stone among others.

Patient presented with lower back pain, and was noted to have [no/one of the] red flag signs or symptoms on presentation [describe].  Patient [reported/denied] preceding trauma.  Patient noted to have a normal neurologic examination in the ED to include deep tendon reflexes in the lower extremities.  Patient felt to have [no indication for imaging at this time/indication for imaging with plain films/MRI of the spine obtained in the ED, and noted to be unremarkable /notable for injury].  Doubt cauda equina or central herniation at this time based on [history and exam/imaging].  No history of recent surgery or injections in the back, fever, or other findings to suggest risk for epidural hematoma or abscess.  Doubt kidney stone or urinary tract infection given absence of urinary symptoms, significant costovertebral angle (CVA) tenderness, [abnormal findings on urinalysis,] or other suggestive findings.  Patient [reported/denied] history of similar episodes [with prior treatments].  Patient reported significant improvement in pain with [treatment] in the ED prior to discharge.

Prior to discharge, we discussed modified activity with emphasis on avoiding prolonged bedrest.  We discussed return precautions, specifically for worsening pain or focal neurologic deficits, treatment with [NSAIDs/muscle relaxants/etc.], and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.  We specifically discussed follow up with primary care doctor for referral to physical therapy and consideration of outpatient imaging.

https://www.acep.org/patient-care/smart-phrases/mri-for-low-back-pain/

https://orthoinfo.aaos.org/en/about-orthoinfo/OrthoInfo-Basics/basics-handouts/

https://orthoinfo.aaos.org/globalassets/pdfs/low-back-pain.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/about-your-back.pdf

https://orthoinfo.aaos.org/globalassets/pdfs/herniated-disk.pdf

https://orthoinfo.org/globalassets/pdfs/2017-rehab_spine.pdf