EM Forum Case #129 "Falling Off the
Wagon"
by Charlene Babcock Irvin, MD, FACEP
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A 24 y/o male is brought in by his mother
with complaints of severe pain in the right
leg. He passed out at home in the bathtub
while taking a shower. He’s not sure how
long he was passed out, but when he came to,
he had severe pain in his right leg, and
couldn’t walk. He crawled to the phone and
called his mother who brought him to the ED.
According to his mother, he was at her house
last night and left around 11:30PM. This
A.M. she stopped by, but 'I figured he was
sleeping because he didn’t answer the door.'
She notes he had to be out for some time.
ROS: He denied any fevers or vomiting.
He did have a headache and a bruise on his
occiput. He denied any neck pain, chest
pain, or abdominal pain. He did have right
leg pain starting at the hip going all the
way down his leg. No diarrhea or urinary
complaints.
PMH: No Surgeries. No
medical problems.
SH: Negative except
for heroin abuse. He recently was discharged
from an inpatient rehab unit in New Mexico.
PE: WDWN male in moderate pain. VS:
140/76, P=120, RR=20, Temp =98.3, Sat=98% RA
HEENT: Unremarkable. C-collar applied in
triage is in place. No neck pain or
tenderness. Full range of motion is noted.
Scalp hematoma at occiput. No hemotympanum.
Pupils are small but reactive.
HEART:
Tachycardic. No Murmurs.
Lungs: Clear
bilaterally.
Abd: Soft, non-tender.
Rectal: Normal tone, guiac negative.
Back: Bruising is noted to right hip and
pelvis area.
Extremities: Right leg
has no movement (0/5 motor exam). Pulses are
palpable at the dorsalis pedis area, but
diminished compared to the left. The leg is
normal color without cyanosis. Sensation is
decreased in that leg.
Neurologic:
Alert, oriented by 3. Motor and sensory
deficit is in right lower extremity.
The trauma team is activated. Accucheck is normal.
IV hydration is started, CT of head, neck is ordered,
along with chest, L/S and pelvis x-ray's. Blood
work is also ordered.
CT of head and
neck is negative. Chest x-ray is normal. Pelvis
and L/S films are negative.
Blood
work reveals:
WBC: 26.4 thousand/cu mm
Hemeglobin: 16.6
BUN: 64 mg/dl
Cr. 2.62 mg/dl
Na: 137, Cl 103, K+=7.2, C02=15, Anion
Gap=19.
U/A: 1.018, trace Glucose,
protein 100 mg/dl, large blood, 6 WBC/HPF,
33 RBC/HPF
Urine Drug Screen: positive
for Opiates
EKG: Peaked T waves,
Right bundle block noted, Tachycardia.
Questions:
1. What
else besides dehydration might be causing
the elevated Creatinine? What Blood test
should you add? If this diagnosis is
confirmed, what is the treatment?
2.
With a negative Head and Neck CT, negative
L/S spine and hip film, what else might be
causing the hemiparesis to the right leg?
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