Case STUDY:

A 57-year-old male construction worker comes to the clinic with a chief complaint of pain in his right hip. The pain has progressively gotten worse over the last 2 months and he has been having trouble sleeping. There is little pain in the morning, but he is a bit stiff.

The pain increases as the day wears on.  has taken acetaminophen without any relief but states that the ibuprofen does work a little bit. He is anxious since the hip pain has limited his ability to work and he is afraid that his boss will fire him if he cannot perform his usual duties.

There is no history of past trauma or infection in the joint. Past medical history noncontributory. Social history without history of alcohol, tobacco, or illicit drug use. Physical exam remarkable for decreased range of motion of the right hip.

BMI 34 kg/mRadiographs in the office demonstrated asymmetrical joint space narrowing of the right hip with osteophyte formation. Several areas of the hip showed bone-on-bone contact with loss of the articular cartilage. The APRN tells the patient he has osteoarthritis (OA) and refers the patient to an orthopedist for evaluation of his need for a total hip replacement.

Question:

Describe how osteoarthritis develops and forms and distinguishes primary osteoarthritis from secondary arthritis.   

Case study:

A 68-year-old man was brought to the emergency department by his family.

During his routine morning walk, he noticed a sudden onset of left facial numbness associated with a dull headache on the right posterior aspect of his head. He was staggering to the right side and feeling unsteady and nauseated, with no vomiting.

He telephoned his wife, who noticed his speech was slow and slurred, but there was no word-finding difficulty. His family immediately took him to the hospital.

There was a history of hypertension, hypercholesterolemia, ischemic heart disease (MI and PCI with a bare-metal stent in 2007), and probable transient ischemic attack (TIA) at the time of cardiac intervention. His medication included atenolol, ramipril, simvastatin, aspirin, and clopidogrel.

Within one hour, the patient’s symptoms had totally resolved. The diagnosis of transient ischemic attack was made, and the patient was discharged to home with instructions to contact his healthcare provider (HCP) for follow-up.

Question:

Why did the patient’s symptoms totally resolve?

Case study:

A 22-year-old male was 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 the 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 a non-rebreather mask and was taken to a Level I trauma center with the following vital signs:

Vital signs: BP 90/50, Pulse 48 and regular, Respirations 24 and shallow with some use of accessory muscles, temp 95.2 F rectally. He was awake and answering questions appropriately but says he cannot feel his arms or legs.

Glasgow Coma Scale 14. His skin was warm and dry with minor abrasions noted on his arms. According to family members, past medical history noncontributory and social history revealed only occasional alcohol use and no tobacco or vaping history.

Full work up in the ED revealed a fracture-dislocation of C4 with assumed complete tetraplegia (formerly called quadriplegia). No other injuries were noted. He was given several liters of IV fluid, but his blood pressure remained low.

Questions:

Explain the differences between primary and secondary spinal cord injury (SCI)? 

What is spinal shock and how it is different from neurogenic shock? 

Case study:

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” whenworking 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  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).

Question:

What is the underlying pathophysiology of MG?  

CASE STUDY:

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.

Question:

What is a seizure and why is status epilepticus so dangerous for patients?