Case 1:

A 26-year-old male was admitted to the hospital complaining of generalized muscle soreness. He had completed the Boston Marathon three days prior to admission. He has become progressively anorexic and lethargic. He also noticed a decreasing amount of urine output over the past three days.

Medical history : Unremarkable and he was not taking any prescription or over the counter medication. He denied alcohol and illicit drug use.

Allergies : None known

Family history : Unremarkable for renal disease.

Physical Exam : Well-developed, well-nourished male appearing lethargic. BP 135/70, pulse 84, respirations 20, temp afebrile, weight 80 kg. HEENT was unremarkable. Cardiac - S1, S2 without S3, S4, murmur or rub. Pulmonary - clear to auscultation and percussion. Abdomen - supple and nontender. Extremities - both lower extremities were tender and had 2+ edema. Neuro - no focal deficits. He was oriented to person, place and time, but was somnolent and had difficulty performing simple mathematical calculations.

Laboratory Data:

Serum: Sodium 138 meq/L, potassium 7.0 meq/L; chloride 101 meq/L, total C02 15; BUN 150 mg/dl; creatinine 10 mg/dl; glucose 100 mg/dl, calcium 7.0 mg/dl, phosphorus 8.0 mg/dl, albumin 3.5 g/dl

Arterial Blood Gas: pH 7.35/28/105/15

Urine: Specific gravity 1.015, pH 6.0, protein 2+, blood 4+, ketones (negative), glucose (negative) 2-5 RBC/HPF, 0-2 WBC/HPF. Na 35 meq/L, creatinine 56 mg/dl, U OSM 320. Renal ultrasound - right kidney 10.8 cm, left kidney 11.0 cm. Normal echogenicity without calculi or hydronephrosis. EKG - normal sinus rhythm with peaked T waves.