Episode #288: When Going To The Gym Goes Wrong (#3)
Apr 23, 2024
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Drs. Baraki and Feigenbaum discuss hospitalizations from exercise gone wrong, including a tragic case of multiple infarctions. They cover evaluating joint pain, return-to-play recommendations post-injury, and a case study of exercise collapse related to sickle cell trait.
Symptoms migration poses diagnostic challenges across multiple body systems.
Appendicitis can present with atypical symptoms, necessitating proactive evaluation.
Recognizing complications in exertional rhabdomyolysis, like sickle cell trait, is crucial.
Deep dives
Presentation and Evaluation of Knee Pain
A 20-year-old female soccer player presents with left medial knee pain that spread to her lower leg, accompanied by loss of appetite, fatigue, and night sweats. Despite an initial clinic evaluation with normal findings, subsequent symptoms led to concerns of systemic inflammation. Labs revealed normal CBC, mild elevation in CRP and ESR. MRI results were normal. Examination in the ED showed abdominal pain, nausea, and vomiting, prompting further assessment.
Widening the Differential Diagnosis
The differential diagnosis includes considerations for joint-related issues, like infections, autoimmune conditions, and malignancies. Systemic inflammation signs suggest the need for contrasted CT for broad evaluation. The change in symptoms and examination findings prompted assessment for appendicitis, revealing an enlarged appendix. Emergent appendectomy led to symptom resolution and full recovery.
Challenges in Diagnostic Process
The migratory nature of symptoms from knee to leg to abdomen highlighted the complexity of diagnosis. The presentation necessitated a broad differential spanning musculoskeletal, abdominal, and systemic conditions. The need for astute evaluation and reliance on diagnostic tools like ultrasound and imaging underscored the challenges of diagnosing interconnected symptoms.
Initial Presentation of Recurrent Severe Leg Pain During Military Fitness Assessment
A 22-year-old African American male college student presented to the emergency room after experiencing severe leg pain during a military fitness test, unable to complete the run due to thigh pain, highlighting concerns of exertional rhabdomyolysis. Despite normal pulses, tenderness in the thighs and elevated CK levels indicated muscle breakdown, treated with IV fluids and rest.
Complications and Tragic Outcome Due to Underlying Sickle Cell Trait
Subsequent hospitalization revealed worsening symptoms, development of compartment syndrome, and signs of disseminated intravascular coagulation (DIC), leading to renal failure and multiple surgeries. Post-mortem tests confirmed sickle cell trait, underscoring the importance of recognizing potential complications, such as exercise-related collapse associated with sickle cell trait and the implications for healthcare management.
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