When pain is out of proportion.

What happened to each of the patients? On re-examination, the first person was in tears and unable to lie still, even after 20 mg of i.v. morphine sulfate. Capillary refill was still intact, but he had lost sensation to the dorsum of the foot and was unable to dorsiflex his toes. He had a marked elevation of compartment pressure, and his creatinine phosphokinase (see below) was twice normal. In the OR, a fasciotomy was performed. Some muscle necrosis had occurred. In the second patient, fluids were infused rapidly on arrival at the ED via the i.v. route. He was given morphine sulfate for pain control while we awaited laboratory results. After about 45 minutes, he produced dark red urine. His creatinine phosphokinase (diagnostic muscle enzyme test) was 190,000--nearly 1,000 times above normal. He also had evidence of liver and kidney damage, but no electrolyte abnormalities. With aggressive treatment, including furosemide and sodium bicarbonate, his kidney and liver function returned to normal, he survived the ordeal and was discharged. The group leaders took the third patient to a local ED, where cellulitis was diagnosed and oral antibiotics were prescribed. The pain and fever increased, and significant discoloration began spreading up her hand over the next 24 hours. The second ED visit resulted in an admission. When the findings progressed despite i.v. antibiotics, surgical exploration was performed with drainage, debridement of devitalized tissue and a change in i.v. antibiotics. The common feature of all of these conditions is pain out of proportion to few, if any, findings on physical examination. Swelling that causes much of the damage in each condition is frequently not appreciated clinically until the condition is well advanced. Remember, what you see is not necessarily what you get.