(Answered) NURS 6501 Week 7 Knowledge Check; Neurological and Musculoskeletal Disorders

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NURS 6501 Advanced Pathophysiology

NURS 6501 Module 5 Week 7 Knowledge Check; Neurological and Musculoskeletal Disorders

  1. Question: A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
  2. Question: A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.
  3. Question: Stan is a 45-year-old man who presents to the clinic complaining of intermittent fevers, joint pain, myalgias, and generalized fatigue. He noticed a rash several days ago that seemed to appear and disappear on different parts of his abdomen. He noticed the lesion below this morning and decided to come in for evaluation. He denies recent international travel and the only difference in his usual routine was clearing some underbrush from his back yard about a week ago. Past medical history non-contributory with exception of severe allergy to penicillin resulting in hives and difficulty breathing. Physical exam: Temp 101.1 ˚F, BP 128/72, pulse 102 and regular, respirations 18. Skin inspection revealed a 4-inch diameter bull’s eye type red rash over the left flank area. The APRN, based on history and physical exam, diagnoses the patient with Lyme Disease. She ordered appropriate labs to confirm diagnosis but felt it urgent to begin antibiotic therapy to prevent secondary complications.  
  4. Question: A 72-year-old female was walking her dog when the dog suddenly tried to chase a squirrel and pulled the woman down. She tried to break her fall by putting her hand out and she landed on her outstretched hand. She immediately felt severe pain in her right wrist and noticed her wrist looked deformed. Her neighbor saw the fall and brought the woman to the local Urgent Care Center for evaluation. Radiographs revealed a Colles’ fracture (distal radius with dorsal displacement of fragments) as well as radiographic evidence of osteoporosis. A closed reduction of the fracture was successful, and she was placed in a posterior splint with ace bandage wrap and instructed to see an orthopedist for follow up.  
  5. Question: A 42-year-old woman presents to the clinic with a four-month history of generalized joint pain, stiffness, and swelling, especially in her hands. She states that these symptoms have made it difficult to grasp objects and has made caring for her 6 and 4-year-old children problematic. She admits to increased fatigue, but she thought it was due to her stressful job as well as being a single mother. No significant past medical history but recalls that one of her grandmothers had “crippling” arthritis. Physical exam remarkable for bilateral ulnar deviation of her hands as well as soft, boggy proximal interphalangeal joints. The metatarsals of both of her feet also exhibited swelling and warmth. The diagnosis for this patient is rheumatoid arthritis.
  6. Question: A 32-year-old Caucasian male presents to the office with complaints of back pain, stiffness, especially in the morning, interrupted sleep due to pain, and difficulty in leaning over to tie his shoes. The patient first noticed these symptoms about 6 months ago but attributed them to his weekend basketball team’s games. He said he is exhausted due to sleep interruption. He has taken acetaminophen with some relief but says the naproxen seems to be working better. Married with 2 small children and works as a bank manager. Physical exam: Lungs clear but decreased chest excursion noted as well as decreased range of motion of hips and forward flexion, rotation, and lateral flexion restricted. Spine radiographs in the office revealed a slight kyphosis along with ankylosis at L5-S1. The APRN suspects the patient may have ankylosing spondylitis (AS). The APRN orders laboratory tests including an HLA-B27. 
  7. Question: A 17-year-old male presents to the clinic with a chief complaint of pain in his right elbow. He says the pain is sharp, especially with pronation and supination.  He noticed the pain several weeks ago after his tennis team went to a regional competition. When he rests, the pain seems to go away. The pain is alleviated when he takes Naprosyn. No history of trauma or infection in the elbow. Past medical and social history non contributary. He is a junior at the local high school and just started taking tennis lessons 2 months ago and his coach is working with him on his backhand serve. Focused physical exam revealed point tenderness over the lateral epicondyle which increases with pronation and supination. The APRN diagnoses him with lateral epicondylitis and orders a wrist splint to prevent wrist flexion.  
  8. Question: A 24-year-old Caucasian male was brought to the Emergency Room (ER) by Emergency Medical System (EMS) after suffering a “convulsion” episode at work that didn’t stop. Upon arrival to the ER, the patient was noted to be actively seizing with tonic-clonic movements. The patient’s boss accompanied him to the ER and gave a statement that the patient appeared in his usual good health earlier in the morning when they started working at their jobs in an auto parts store. The boss didn’t know of any past medical history. The boss brought along the patients next of kin information, and the patients mother told the ER that the patient has a prior history of seizures but hadn’t had a seizure in several years. The family thought he had “outgrown them.” Past medical history, other than previous seizures, and social history non-contributory. No history of alcohol or drug abuse and had no history of vaping. The ER APRN diagnoses the patient with status epilepticus and along with the ER staff, initiated appropriate treatment.
  9. Question: A 32-year-old while female presents to the Urgent Care with complaints of blurry vision and “fuzzy thinking” which has been present for the last several weeks or so. She works as an executive for an insurance company and put her symptoms down to the stress of preparing the quarterly report. Today, she noticed that her symptoms were worse and were accompanied by some fine tremors in her hands. She has been having difficulty concentrating and has difficulty voiding. She remembers her eyes were bothering her a few months ago and she went to the optometrist who recommended reading glasses with small prism to correct double vision. She admits to some weakness as well. No other complaints of fevers, chills, upper respiratory tract infections, or urinary tract infections. Past medical and social history noncontributory. Physical exam significant for 4th cranial nerve palsy. The fundoscopic exam reveals edema of right optic nerve causing optic neuritis. Positive nystagmus on positional maneuvers. There are left visual field deficits. There was short term memory loss with listing of familiar objects. The APRN tells the patient that she will be referred to a neurologist due to the high index of suspicion for multiple sclerosis (MS).  
  10. Question: 61-year-old male complains of intermittent weakness and muscle fatigue that has progressively worsened over the past month. He was an internationally known extreme mountain climber but now he says he has difficulty in getting his morning paper. Initially he thought his symptoms of profound leg weakness and fatigue were due to his age and history of injuries from mountain climbing. Over the past few months, he also reports having noticed “blurriness” when working on his antique train collection or reading for long periods of time. He has developed intermittent double vision that seems to be worse when reading at bedtime. He also reports an occasional “droopy” eye lid. Past medical and social history noncontributory. Physical exam reveals weakness of right extra ocular muscle (EOM) with repetition. There is positive nystagmus and symmetrical upper extremity weakness with fasciculations. Lower extremities within normal limits (WNL).   The APRN suspects the patient has myasthenia gravis (MG).  
  11. Question: A 67-year-old male presents to the clinic along with his family with a chief complaint of having problems with his short-term memory. His family had dismissed these problems and attributed them to the aging process. Over time they have noticed changes in his behavior, along with increased confusion and difficulty completing basic tasks. He got lost driving home from the bowling alley and had to be brought home by the police department. He is worried that he may have Alzheimer’s Disease (AD). Past medical and social history positive for a minor cerebral vascular accident when he was 50 years old but without any residual motor or sensory defects. No history of alcohol or tobacco use. Current medication is clopidogrel 75 mg po qd.  Neurological testing confirms the diagnosis of AD. 
  12. Question: A 22-year-old male was an unrestrained front seat passenger of a car traveling at 50 miles per hour. The driver swerved to avoid hitting a deer that darted in front of the car and hit a tree. The patient was ejected from the vehicle. He was awake and alert at the scene when the paramedics arrived, and his pupils were equal and reactive to light. He was placed in a hard-cervical collar per protocol and log rolled onto a long backboard. He was breathing spontaneously at the scene, but pulse oximetry in the EMS unit revealed a SaO2 of 88% on room air. He was placed on 100% oxygen via non-rebreather mask and was taken to a Level I trauma center with the following vital signs: 
  13. Question: A 22-year-old male was an unrestrained front seat passenger of a car traveling at 50 miles per hour. The driver swerved to avoid hitting a deer that darted in front of the car and hit a tree. The patient was ejected from the vehicle. He was awake and alert at the scene when the paramedics arrived, and his pupils were equal and reactive to light. He was placed in a hard-cervical collar per protocol and log rolled onto a long backboard. He was breathing spontaneously at the scene, but pulse oximetry in the EMS unit revealed a SaO2 of 88% on room air. He was placed on 100% oxygen via non-rebreather mask and was taken to a Level I trauma center with the following vital signs: 
  14. Question: A 22-year-old male was an unrestrained front seat passenger of a car traveling at 50 miles per hour. The driver swerved to avoid hitting a deer that darted in front of the car and hit a tree. EMS on the scene noted a stellate fracture of the windshield on the passenger side. The patient was non-responsive at the at the scene when the paramedics arrived, and his pupils were unequal with the left pupil larger and sluggish to react to light. He was placed in a hard-cervical collar per protocol and log rolled onto a long backboard. He was breathing spontaneously at the scene, but pulse oximetry in the EMS unit revealed a SaO2 of 78% on room air. He was intubated at the scene for airway protection and transported to a Level 1 trauma center. Glasgow Coma Scale=3 
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  17. ……20. Question: A 34-year-old Caucasian female presents to the clinic with a chief complaint of widespread pain in her joints and muscles. She states that her skin seems sensitive and sometimes it hurts to be touched. 

ANSWER  

  1. A 52-year-old obese Caucasian male presents to the clinic with a 2-day history of fever, chills, and right great toe pain that has gotten worse. Patient states this is the first time that this has happened, and nothing has made it better and walking on his right foot makes it worse. He has tried acetaminophen, but it did not help. He took several ibuprofen tablets last night which did give him a bit of relief. Past medical history positive or hypertension treated with hydrochlorothiazide and kidney stones. Social history negative for tobacco use but admits to drinking “a fair amount of red wine” every week. General appearance: Ill appearing male who sits with his right foot elevated. Physical exam remarkable for a temp of 101.2, pulse 108, respirations 18 and BP 160/88. Right great toe (first metatarsal phalangeal [MTP]) noticeably swollen and red. Unable to palpate to assess range of motion due to extreme pain. CBC and Complete metabolic profile revealed WBC 14,000 mm3 and uric acid 8.9 mg/dl. The APRN diagnoses the patient with acute gout.

Question 1 of 2:

Describe the pathophysiology of gout.

Gout- an inflammatory response to excessive quantities of uric acid in the blood (hyperuricemia) and in body fluids, including synovial fluid (McCance et al., 2019). At the cellular level, purines are synthesized to purine nucleotides- used in the synthesis of nucleic acids, adenosine triphosphate, cyclic adenosine monophosphate (cAMP), and cyclic guanosine monophosphate (cGMP) (McCance et al., 2019). Uric acid is what results from the breakdown of purine nucleotides. Those with gout may have accelerated purine synthesis with an overproduction of uric acid while others break down purine nucleotides at an accelerated rate, resulting in an overproduction of uric acid (McCance et al., 2019). A deficiency of HGPRT enzyme can lead to an increased production of uric acid while a complete absence of HGPRT is uncommon but can occur in X-linked Lesch-Nyhan syndrome, with males at risk for hyperuricemia, neurologic alterations, and sometimes gouty arthritis (McCance et al., 2019). Primary gout results when there is an unknown metabolic defect while secondary gout is when the etiology is known.

With primary gout, urate excretion by the kidneys is sluggish possibly due to a decrease in glomerular filtration or accelerated urate reabsorption. Monosodium urate crystals stimulate and perpetuate the inflammatory response while the presence of MSU crystals triggers the acute inflammatory response (McCance et al., 2019). Cytokines and interleukins are activated which draw neutrophils out of the circulation and begins phagocytosis of the MSU crystals. Inflammatory mediators are released during this time, including interleukins, chemotactic factors, lysosomal enzymes, eicosanoids, prostaglandin E, reactive oxygen species, and collagenase (McCance et al., 2019).…….Please click the icon below to purchase full answer at $20