Mystery Quiz

July 2, 2014

Vivian Hayashi MD, Robert Smith MD

A 51 year old man presented to the emergency room with fever and myalgias for four days. The patient was previously in good health except for occasional asthmatic exacerbations. He noted thigh pain in the few days prior to admission, for which he took about 8 tablets of ibuprofen. Additional symptoms included anorexia, epigastric pain, emesis that was neither bloody nor bilious, and loose stools. The patient also noted that his urine was dark colored and he experienced perioral tingling. The history was negative for illicit drug ingestion, statin usage, alcohol abuse, or excessive exercise. On exam, the patient appeared lethargic; the BP was 130/90 mmHg, PR 93, RR 18, and temp of 101.2. Positive findings included chest exam with crackles over the left base and an abdominal exam with mild tenderness of the LLQ to palpation. The neuromuscular exam was unremarkable. Admission labs showed a WBC of 19k with 14% bands, HGB 17gm/dl, platelets 184k, Na 131 meq, BUN/creatinine 32/3.0 (had been normal previously), serum calcium 5.7 (ionized calcium 0.58), phosphate 11.3, AST/ALT 2006/308, LDH 16,220 U/L, normal INR, and CPK 690,000 IU/L. The chest radiograph is shown below:











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