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MUSCLESKELETAL CASE STUDY ANSWERS

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

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