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MUSCLESKELETAL CASE STUDY ANSWERS

MUSCLESKELETAL CASE STUDY ANSWERS

64 Y/O inmate was found down in prison yard; his right arm was pinned under his body. He is African American, has been in prison for 10 years and a religious body builder. Ht 5’9” and Wt. 450#. He is brought to ER by rescue and not responding to verbal or tactile stimuli. No inmates were willing to provide background information on events or time line. Guards with client state routine yard rounds are done every 30 minutes. You are the triage provider. The general survey shows a well developed male who looks younger than stated age. He is bradycardic with clear lungs. Initial EKG shows peaked T waves, prolonged PR interval; sinus bradycardia. His right arm is swollen twice the size of the left. Right brachial and radial pulses are thready.

SUBJECTIVE

  • Initial report = pt down 30 minutes
  • Guards state possibly could be > 30 minutes, maybe up to 1-1.5 hrs
  • UTA d/t unresponsiveness & no background info from other inmates
  • Guards who found him report he exercises at least 4 hours/day, is present for all meals and has a healthy appetite; very serious about health
  • Not feeling well for about a week; today hit the weights extra hard (overheard other inmates)

OBJECTIVE

VS

Labs

EKG

Pt. presentation

HR 56

BP 90/50

TEMP 37

RR 20

K 7.23

CK ~ 3500

pH 7.32

SrCr 4.3

 

Peaked T-waves

MI r/o

Diaphoretic, pale, pupils sluggish but reactive & equal

 

  • Data indicates hyperkalemia

Causes

  • RBC destruction
  • Excessive K supplements
  • T1 DM

ADDITIONAL INFO

  • Medical hx from prison records: T2 DM
  • Meds/supplements? Religious about multi-vitamin; sulfonurea for DM; unsure if compliant
  • Prior hx of similar events? NO
  • Head to toe: WNL; looks approximately stated age
  • MSK: right arm red and swollen; right shoulder dislocated; no broken bones; passive ROM intact
  • Neuro: pupils sluggish but reactive; cannot assess orientation

DIFFERENTIAL DIAGNOSES

Causes of AKI

Supporting Evidence in Patient

Acute hyperglycemia 2/2 DM

Pt has known diagnosis of T2 DM on sulfonurea

Drug-induced:

 

  • Beta blockers, ACEI

Not prescribed

  • Steroid use

Suspected use

Hyperthyroidism

Not diagnosed

Dehydration

Last seen eating/drinking 3 hrs prior

Exercise-induced w/rhabdo

Possible

Exercise-induced w/out rhabdo

Possible

Compartment syndrome

Bradycardia (final stage of compartment syndrome – decreased perfusion = weak pulse

 

PROBLEM LIST

  • Compartment syndrome
  • Metabolic Acidosis

PATHOPHYSIOLOGY OF PROBLEM

Heavy exercise -> compartment syndrome -> -> rhabdo -> acute elevation in CKs -> acute kidney injury -> hyperkalemia -> bradycardia -> weak/thready pulse -> loss of consciousness

PLAN OF CARE

  • Urinary catheter
  • Insulin & dextrose gtt
  • Reverse SB & hypotension w/ fluids + atropine/dopamine/epi?
  • Correct hyperkalemia
  • Likely surgery for compartment syndrome
  • Likely intubate r/t airway protection since pt is unresponsive

Future Education

  • Use caution in weight/strength training, especially after a break in routine
  • Assess medication compliance

REFERENCES

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056317/

https://www.ncbi.nlm.nih.gov/pubmed/23425757

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0082992

https://www.mayoclinic.org/symptoms/hyperkalemia/basics/causes/sym-20050776

 

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