Labs: K elevated 6.6 CO2 low 16 BUN high 98 Creatinine high 9.6 AST high 125 ALT high 85 Creatinine kinase high 112,000 EKG: borderline ST Tall peaked T waves present UA: color – cola-like Low osmolarity Blood positive +4 2+ urate crystals Casts: 20-30 muddy brown Creatinine: 68 Occult blood: positive Urice acid: 8.3 (high) Chief complaint: “I’m really hurting, I hope you can help.” Brief HPI: R.J. is a 31 year old Hispanic male who presents with a chief complaint of a progressively worsening 2 day history of thigh and back muscular pain and generalized weakness. Patient states he recently performed a high intensity workout program. High-dose ibuprofen has not relieved his pain. Symptoms include a poor appetite, nausea and vomiting for 2 days, reduced food and fluid intake. Patient denies any recent intoxication, toxin exposure, or recent trauma. Physical exam shows a hypertensive BP, and positive orthostatic drop in BP upon standing, tender muscles, and dry mucous membranes. PMH: None Past Surgical History: None Social History: - Tobacco use: Never smoker - Drug use: Denies - Alcohol use: 1-2 beers/day - Marital status: Single, currently dating - Sexual orientation: male - Sexually active: Yes currently, uses condoms - Living situation: Lives at base Past Family History: - Father: Alive, age 52, healthy - Mother: Alive, age 50, obese, type II diabetes - Brother: No health issues - Offspring: Unable to obtain health status of his 4 year old daughter (lives out of state with ex-spouse) Allergies: No known drug allergies Active Medications: Ibuprofen PRN for pain Multivitamin, occasional use ROS: - GENERAL: Admits to recent generalized weakness. Overall generally feels healthy. - SKIN: Denies any rashes or petechia, discharge, or abnormal pruritus. Denies any new skin lesions, hair loss or increase, or breast changes. - HEENT: Denies double or blurred vision, photophobia, discharge from eyes, or vision loss. Denies any abnormal nasal discharge, pain, or epistaxis. Denies hearing loss or tinnitus. - CV: Denies chest pain, discomfort, pressure, pain, or dizziness with exertion. Denies palpitations, decreased exercise tolerance, or blue/cold fingers and toes. - RESP: Denies any shortness of breath at rest and on exertion. Denies cough, difficulty catching breath, sputum production, or any wheezing. - GI: Admits to recent nausea and vomiting for past 2 days. Denies any abdominal pain, diarrhea, constipation, blood in bowel movements, or coffee ground emesis. - GU: Admits to decrease in urination. Denies any urinary incontinence, difficulty urinating, hematuria, or increase in frequency. Denies any polyuria, polydipsia, nocturia, burning or pain during urination, or difficulty starting/stopping urinary stream. - NEURO: Admits to recent lightheadedness. Denies any memory loss, headaches, dizziness, spinning room, seizures, weakness, numbness, tingling, or tremors. - MUSCULOSKELETAL: Admits to recent weakness and pain in back and legs. Denies any problems with joint pain, ROM, strength, or balance. - PSYCH: Denies any mood changes or loss of interest/pleasure in doing things. Denies feelings of depression or any visual or auditory hallucinations at this time. Denies any nervousness or sadness. Vital Signs: T: 98.4F PO P: 96 bpm - regular BP: 166/100 (supine/sitting), 140/78 (upon standing) RR: 1