Author: Aaron Tracy, MD, MHMS
Co Author #1: Andrew Li-Yung Hing, MD, FAAFP, CAQSM

Patient Presentation:
Dark urine and Intense leg pain

History:
The patient is a 26 year-old incarcerated African American male with no significant past medical or surgical history who presented to the emergency department with 1-day history of intense bliateral leg pain and dark urine. The patient states that the previous day he completed an air squat pyramid workout (Started at 1 and progressed to 50, increasing his squat total by 1 each time) that totaled about 1225 air squats over a 2-hour period. He drank only a little water during the workout and felt fine after the workout with only had some mild soreness in his quadriceps. He states that he woke up the next morning with extreme pain in both of his thighs and also had dark, ginger ale colored, urine without seeing any blood. He went to the jail infirmary where he was given Naproxen and Medrol. His Urine showed excessive blood fragments. He was immediately sent to the emergency room for further work-up. He smokes marijuana socially and takes Alprazolam for sleep at night. In the Emergency room, the patient was afebrile, normotensive, normal heart rate and normal respiratory rate on room air. His creatine Phosphokinase level was greater than 40,000 and was given 1 liter bolus of normal saline. The patient was admitted to the hospital for further management and care.

Physical Exam:
Constitutional: Oriented to person, place, and time and well-developed, well-nourished, and in no distress
Head: Normocephalic and atraumatic
Eyes: Conjunctivae, EOM are normal; Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion.
Right upper leg: He exhibits tenderness. He exhibits no bony tenderness, no edema and no deformity. 2+ palpable pulses. Sensation to light touch and vibration intact
Left upper leg: He exhibits tenderness. He exhibits no bony tenderness, no edema and no deformity. 2+ palpable pulses. Sensation to light touch and vibration intact
Neurological: He is alert and oriented to person, place, and time. He has normal reflexes in all extremities. Gait normal.
Skin: Skin is warm.
Psychiatric: Affect and judgment normal.

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