Exertional Rhabdo A/P

PE:
EXTREMITIES-Upper:
-Swelling of the L arm w/out underlying erythema. Extending from the biceps to the mid forearm. Biceps diameter measured to be 30cm, increased from 29cm yesterday. Pain on passive extension. Active ROM limited due to pain. 1+ radial pulse.
-Swelling of the R arm w/out underlying erythema. Less than the R arm. Biceps diameter is 26 cm, stable from yesterday. Full ROM. Pain present, but less than the L arm. 2+ radial pulse.

Impression: ER w/ or w/out heat injury. +/- AKI 

CHAMP GUIDELINE
https://www.usuhs.edu/sites/default/files/media/mem/pdf/clinical_practice_guideline_for_managing_er.pdf


1. Exertional Rhabdomyolysis- CK trend (36 -> 42 -> 39 -> 44 -> 43). Likely beginning to plateau and would expect to start downtrending later today. Symptoms unchanged from yesterday. No evidence of AKI and improving BUN/Cr. Metabolic abnormalities significant for mild hypocalcemia. Hypocalcemia is expected w/ early exertional rhabdomyolysis and is directly related to degree of muscle destruction. Will not correct for hypocalcemia as this can worsen heterotopic calcification and exacerbate hypercalcemia during resolution phase.  

-CTM w/q6 BMP and CK
-Will begin to titrate off fluids after two consecutive values CK of 32,000 U/L or less and commence trial of oral hydration
-Will assess oral hydration and leave IV access in place while continuing to monitor CK
-CTM calcium levels, should only treat if patient has evidence of cardiac dysrhythmias or seizures, per CHAMP guidelines

-Discharge planning:
    -Pt still at risk for repeated AKI up to 6 weeks after admission. Pt should not have any known nephrotoxic agents during this time (NSAIDS, IV contrast, etc).
    -Although pt appears to have maintained her baseline cr of 0.97, should monitor closely. If elevations after 2 weeks, should consult nephrology.
    -Since first episode of ER, no further outpatient workup needed.
    -F/u w/PCM, pt has appointment scheduled in early DEC.
    -Will continue to trend CK's to determine whether pt can dc today or tomorrow. 

2. Arm swelling - potential  to develop compartment syndrome, well-known complication of ER. Monitoring for signs/symptoms.  Mild pain on passive stretching of biceps, no paresthesias of the involved extremity.  Good distal radial pulses. No increased tension or turgor of the involved muscle groups. Increase in R biceps swelling by 1cm in diameter (29 -> 30cm) from yesterday. No active concern for compartment syndrome, but will monitor closely given her increased swelling. 
-Continue compartment measurements
-If pt begins to develop symptoms of paresthesias, decreased ROM, will consult ortho and measure compartment pressures.