NUR 631 Topic 13 DQ 1

Sample Answer for NUR 631 Topic 13 DQ 1 Included After Question

Answer all of the following questions for your discussion response. Use the format displayed in the “Discussion Forum Sample.”

A 28-year-old woman was admitted to the general internal medicine service with a 3-day history of malaise and cough that progressed to include myalgia, generalized weakness, and dark-colored urine. Three days before admission, she had an abrupt onset of a dry nonproductive cough, malaise, and anorexia that resulted in a prolonged period of fasting. On the second day of the illness, she awoke with diffuse muscle pain and progressive weakness, culminating in an inability to walk. She subsequently noted dark urine and presented to the emergency department, leading to this admission. She had no recent trauma, exercise, rash, joint pain, or foreign travel. She was taking a multivitamin supplement but no prescription medication.

At presentation, she was mildly distressed but oriented. Her vital signs were within normal limits, apart from mild tachycardia (heart rate, 104 beats/min). Physical examination revealed grade 3/5 limb muscle strength, although testing was associated with obvious discomfort. Muscle bulk and tone, tendon reflexes, and sensation were normal. Notably, there was no rash, and cardiorespiratory examination yielded unremarkable findings. Initial chest radiography revealed a left lower lobe infiltrate most consistent with pneumonia. Urinalysis was strongly positive for hemoglobin. Initial laboratory analysis (reference ranges provided parenthetically) revealed that her creatine kinase (CK) level was markedly elevated at 118,342 U/L (38-176 U/L).

  1. What is the most appropriate next step to confirm the diagnosis of rhabdomyolysis in this patient? Provide an explanation for your answer.
  2. What is the most likely etiology of this patient’s recurrent rhabdomyolysis?
  3. Rhabdomyolysis is a rapid breakdown of muscle. Detail the pathophysiology behind rhabdomyolysis.
  4. What are the possible complications of rhabdomyolysis?
  5. Which medications may cause rhabdomyolysis?

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A Sample Answer For the Assignment: NUR 631 Topic 13 DQ 1

Title: NUR 631 Topic 13 DQ 1

Please discuss the pathophysiology, clinical manifestations, and evaluation/treatment of one of the many pediatric musculoskeletal disorders.

Duchenne Muscular Dystrophy Pathophysiology: Duchenne Muscular Dystrophy (DMD) is an X-linked inherited muscular disease primarily affecting males. It is caused by deletion of one or more exons of the DMD gene on the X chromosome or, by a rare nonsense mutation (McCance et al., 2019). The DMD gene is responsible for dystrophin production, a membrane-stabilizing protein absent in DMD. Dystrophin mediates the anchorage of the actin cytoskeleton of skeletal muscle fibers to the basement membrane.

Without adequate anchorage of the basement membrane, these poorly organized fat and connective tissue strands cannot develop normal musculoskeletal anatomy. The contraction physiology leads to unorganized forces exerted on disease muscle cells and destroys them. Free calcium is released and causes muscle cell death. Children under three generally can regenerate some muscle cells and sustain some normal functions until the muscle cell death rate exceeds regeneration. Clinical onset of DMD is rapid and occurs around three to four years old.

Clinical Manifestations:  Difficulty walking, gait instability, waddling, frequent falls, and difficulting standing are signs that parents will seek care for. Significant lumbar and gluteal muscle weakness presents as a child that rises from standing by bracing on their own legs and thighs to stand (Gower sign). The shoulders also become affected but typically after lower body manifestations. A hallmark pathology sign of DMD is pseudohypertrophic calf muscles consisting of fat and connective tissue rather than muscle tissue (McCance et al., 2019). The feet assume equinovarus positioning, and ambulatory children tend to walk on their toes.

It is typical for loss of ambulation to occur around 12 to 15 years old. Intellectual disability is a common component, although learning disability is thought to contribute to lower-than-average IQs. The life expectancy for DMD has been increasing, but patients often have high mortality with respiratory complications. Scoliosis and kyphosis are common complications, resulting in respiratory insufficiency, pneumonia, and chronic aspiration risk. The average life expectancy of DMD is around 20 to 25 years old. Patients with Becker muscular dystrophy, a less severe variation of DMD have a life expectancy of 30 to 40 years old. Cardiac complications also accompany many inherited diseases.

Evaluation and Treatment Options:

Prenatal diagnosis is now possible and female carriers can be identified, especially if there is a known genetic defect in another family member (McCance et al., 2019). Due to rapid muscle breakdown and death, serum enzymes (CPK, LDH, SGOT, aldolase) are often elevated. CK increase can be 100 to 1,000x normal and CK elevation in infants is indicative of DMD. Patients may require ventilatory support throughout their life, and multidisciplinary care models are required to optimize health and quality of life for these patients.

References

McCance, K. L., Huether, S. E., Brashers, V. L., Rote, N. S., & McCance, K. L. (2019). Pathophysiology: The biologic basis for disease in adults and children. Elsevier.

A Sample Answer 2 For the Assignment: NUR 631 Topic 13 DQ 1

Title: NUR 631 Topic 13 DQ 1

Developmental dysplasia of the hip (DDH), also known as congenital hip dysplasia (CHD), is one of the commonest musculoskeletal pathologies in the newborn (Nievelstein, 2021). It is a developmental (and not a congenital!) disease of the hip as newborns with normal hips at birth can be affected later during infancy (Nievelstein, 2021). Therefore, CHD is a misnomer and should be avoided (Nievelstein, 2021).

DDH occurs in approximately 1:1000 live births with a female predominance (Nievelstein, 2021). The left hip is more commonly involved than the right hip, and it can occur bilaterally (Nievelstein, 2021). Risk factors include breech position during pregnancy (girls 12%, boys 2.6%) and a positive family history (girls 4.4%, boys 0.9%) (Nievelstein, 2021). Clubfoot has been thought to be a risk factor but this no longer holds true (Nievelstein, 2021).

Ultrasound (US) is the imaging technique of first choice in infants younger than 6–9 months of age with suspicion of DDH (Nievelstein, 2021). After this age the physiological ossification of the femoral epiphyses usually obscures an adequate overview of the entire hip joint and a pelvic X-ray is preferred (Nievelstein, 2021). With US we are looking at the same anatomic structures as on a pelvic X-ray, with the advantage of also displaying the cartilaginous structures of the hip joint (Nievelstein, 2021). DDH on US is classified according to the Graf classification in types I–IV based on the morphology of the iliac bone, including the shape of the acetabulum, the bony and cartilaginous acetabular rim, labrum, and position of the femoral head (Nievelstein, 2021). It has been shown that US can also be used for guidance and follow-up of manually as well as operatively reduced dislocated dysplastic hips (Nievelstein, 2021).

Nievelstein, R. A. (2021). Non-traumatic musculoskeletal diseases in children. In IDKD Springer series (pp. 283–292). https://doi.org/10.1007/978-3-030-71281-5_20