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The Disintegration of Damaged Muscle Tissue: Rhabdomyolysis

Introduction

Rhabdomyolysis is a condition that leads to the disintegration of damaged muscle tissue. Through the disintegration of the muscle tissue, the skeletal structure of the body becomes weak. In addition, the residue from the disintegration process may accidentally be deposited into the blood stream giving the liver and the kidney a lot of work to purify it. This may lead to the development of adverse conditions such as kidney failure (Domino, 2011).

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Other symptoms include vomiting, confusion, muscle pains. The severity of these symptoms depend on the extent of muscle disintegration and kidney failure.

The condition may arise because of physical factors that lead to the damage of body tissues and structures. It may also arise because of inheritance of certain genetic traits from related individuals (Howard & Thorson, 2008).

Physical causes include accidents, crushes, and strenuous exercises. These factors lead to the overworking of the body and straining of muscles, factors that contribute greatly to the development of the condition (Johns & Freshwater, 2006).

On the other hand, some individuals may inherit muscle structure from their parents that are prone to the condition. This situation makes them more vulnerable to the condition as compared to other individuals who have a strong muscle structure.

Other causes of rhabdomyolysis include medication, drug abuse, and infection. There are some prescribed medicine (such as statins and fibrates) that may lead to the weakening of the muscle structure of body tissues. In other instances, excessive use of string drugs such as a alcohol, cocaine, marijuana and heroin may lead to the development of the condition.

Some infections such as influenza, malaria and HIV may render the body weak and thus prone to the disease (Mildon & Underwood, 2010).

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Mechanism of infection of infection may take several forms. Injuries that arise from crushes and other physical processes affect the tissue itself. These injuries may also lead to poor blood supply in the tissues. Physical injury may lead to the direct damage of muscle cells. As a result, the damaged tissues slowly fill up with fluids from the blood stream that leads to swelling and accumulation of ions such as calcium. This leads to increased muscle damage. In the process, many cells die and those that remain alive are subjected to constant disruption. In addition, there is prolonged muscle contractions that may lead to the breakdown of intercellular proteins that may finally lead to the disintegration of the cell (Poels, 1993).

On the other hand, non-physical injuries may result to muscle cell metabolism interference. This results to reduced energy production and uptake. As a result, an individual becomes weak and cannot be involved in vigorous exercises.

The swollen muscle may lead to the development of compartment syndrome. In addition, the cell may release phosphates, calcium ions, and other substances into the blood stream. The release of these substances may lead to kidney failure. This may arise as a result of the kidneys being overworked.

In addition, the condition can also cause renal failure. This may result due to the accumulation of myoglobin and other substances in the kidney tubules. This condition alters the re-absorption process of the kidney. As a result, concentrated urine that is orange or dark yellow is released. This process is further worsened by the accumulation of uric acid that increases the concentration of urine.

Patients History

Name: Kenny Baltimore. Address: 35th Street, Eastwood USA. Age: 68. Sex: Male. Marital Status: Widowed. Race and Ethnicity: African American. Occupation: Retired Army General.

The patient had come to the hospital after experiencing persistent muscle pains for over six days, decreased appetite, dark yellow urine, fatigue and a general weak body condition. From observation, these signs were a likely indication of fatigue, strenuous exercises or any other condition that may cause physical tear and wear of the body. Further examination was necessary for the correct diagnosis to be made.

The patient reported that the muscle pains started after he had a car accident six months ago. Immediately after the incident, he used to experience pain in most parts of the body, especially in the joints. He also experience the swelling of muscle and joins especially on the knees.

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All these complication came about because of the crush injury that the patient experienced during the accident. The patient also experienced other physical injuries like a broken wrist, sprained left ankle and bruises on his body.

However, the pain in the muscles had become severe for the last seven days. In addition, he had started to lose appetite. For the last one month, he had been discharging dark orange urine. The patient thought that the discharge of dark orange urine was because of dehydration thus he increased his water consumption.

Since the patient is a retired war veteran, he is not engaged in many activities during the day other thank watching TV and visiting friends and relatives. He has a strict diet that is free from any meat, either red or white. He prefers to eat vegetables to maintain his health. After the death of his wife 5 years ago, the patient has been living with his daughter, whom most of the time is out of the city as she is a model. Therefore, there is a high chance that the patient does not eat well-cooked meals at home. In addition, he does not have a girlfriend and has not been engaged in sexual intercourse for many years now.

At his age, excessive consumption of alcohol and smoking may have profound effects on his health. The use of these drugs may have contributed greatly to the current symptoms that he had such as the color of his urine and decreased appetite.

His past medical history included human immunodeficiency virus (HIV), hyperlipidemia, benign prostatic hyperplasia, chronic obstructive pulmonary disease, hypertension, atrial fibrillation, pacemaker insertion, coronary artery disease with myocardial infarction. These conditions, especially HIV could explain many physical symptoms that were present on the patient. The patient was diagnosed with coronary heart disease 3 years ago. In addition, pacemaker incursions were done 6 months ago to stabilize the rate of his heartbeats. Hypertension on the other hand increased his blood pressure. All these factors put him in a risk of suffering a heart attack.

All through his medical history, the patient had never suffered from and renal disease. In addition, the condition had never been reported to any of his family member or close relatives. He had a creatinine baseline of 0.9 mg/dl.

The patient was under medication for the last several years. 15 days prior to being hospitalized, the patient was taking 80mg of simvastatin every day. Before this, he had been taking 40mg of atorvastatin for 18 months. No adverse side effects were ever reported because of the use of these drugs.

For his HIV condition, the patient had been taking 400 mg atazanavir and 40 mg stavudine once before sleeping and twice a day respectively. These drugs had been administered to him for the last two years.

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This information clearly shows that the chances of the patient inheriting Rhabdomyolysis from his parents is minimal as it has never been reported in their family history. In addition, no cases of renal infection have ever been reported in the family. this clearly indicates that if the condition arises, then it may have originated from the patient himself. The chances of hereditary transmission are minimal.

The son of the patient, who is 37 years old is suffering from arthritis. He was diagnosed 15 months ago. The condition was so severe that he had to quite from his basketball team as a professional player.

Review of systems

General Symptoms – the patient had a temperature of 38.1⁰, a heart rate of 62 BPM, blood pressure of 101/30 and a respiration of 21 breaths per minute. As reported by the patient, his skin is of normal condition, not too dry or too oily. The patient has never experienced any pain or persistent problem with his neck or head. The patient says that he has been experiencing dry coughs occasionally. Despite the fact that the patient has never experienced any serious chest pains, he has a heart condition. He is suffering from coronary heart disease that was diagnosed three years ago. The patient has a few problems with his gastrointestinal system. He complains of loss of appetite and diarrhea. However, he denies vomiting and nausea. The dry coughs might be as a result of his chain smoking, a habit that may have affected his chest and lungs. Despite this problem, he says that he does not have any problems with breathing and neither does he suffer from any respiratory disease such as bronchitis or tuberculosis. This was supported by an x-ray of his chest that was taken 6 months ago. To stabilize his heart, the patient has pacemakers and is under constant medicine.

As a result of his diet, the patient does not eat either red meat or white meat. He prefers to eat corn, vegetables, cereals and fruits.

The inactivity of his sexual life, may be as a result of the death of his wife, his age and his current HIV status. The patient admits that he does not want to be in any relationship due to the fear of transmitting the virus.

The car accident might be the main cause of the problem that he is currently experiencing.

After the patient was diagnosed with HIV and the resultant death of his wife, he has been finding it difficult to cope with the realities of life. Due to this fact, he has increased his alcohol intake. He has tried to join several rehabilitation groups all of which have not succeeded to change his drinking habits.

Physical Assessment

The patient was 6’ 2’’ tall and weighed 160 Ibs. The patient had a temperature of 38.1⁰. A heart rate of 62 BPM. Blood pressure of 101/30. Respiration of 21 breaths per minute. The weight was normal for a person his size. The high temperature indicated that the patient was suffering from fever and hyperthermia. He also had a slightly high blood pressure. His breathing rate and heart rate were relatively normal.

His skin turgor was normal. His pupils were of the same size and reacted normally to light. No papilledema was found. The ears were normal, had a proper articlular alignment and had no foreign bodies on the canal. His nose was normal, the nostrils were of the same size and symmetrical to one another and the nasal mucosa was oink in color. The normal skin turgor was an exhibit that the body was not dehydrated. The other signs were an indication of normal healthy condition. The patient had perfect hearing capabilities.

The buccal cavity was pink. The patient had 31 teeth, one premolar was removed when he was in the army as a result of tooth decay. There was presence of cavity. Finally, the tongue movements were excellent. The neck was to touch, supple and had no signs of jugular venous distention.

The patient had a breathing rate of 21 breaths per minute on average. The anterior and posterior diameter of the lungs were as expected and the patient had no signs of any respiratory infection. His chest had no auscultation and percussion.

Due to his heart condition, the patient had pacemaker incursions. The radial pulses were equal bilaterally while the pedal pulses were palpable. The abdomen was soft with no organomegaly.

Musculoskeletal system

The movements of the neck were normal. The hands were able to make fists and unfold. The elbows were able to stretch and fold. The reflexes of the knees, ankles, quadriceps and biceps were normal. The hip flexion was 80/90⁰ on both sides although the patient complained of slight pain. Both the hands and the legs were of the same size when measured. There was swelling on joints, especially knees.

Nurse Diagnosis

Rhabdomyolysis is diagnosed by the use of the following tests: biopsy, blood tests, Urine sample, Computed tomography scan, Magnetic resonance imaging. When administered effectively and efficiently, these tests should reveal the presence or absence of rhabdomyolysis in an individual. The condition is suggested by the past history of an individual. It is finally confirmed with the help of urine and blood tests (Wolfson, 2009). All these will be discussed in this section.

Biopsy

It is essential to conduct a biopsy to determine the extent of muscle infection as a result of the disease. In this particular case, a sample of the patient muscle was extracted and taken to the lab for further analysis. The muscle sample was extracted by cleaning the skin, numbing it and removing the sample. After the small operation, the region that the sample was extracted from was stitched to ensure faster healing and also to prevent entry of germs.

Blood test

A complete blood count was conducted on the patient. This test was done to determine the level of Creatine kinase and other enzymes such as SGOT, SGPT and LDH. Their levels were found to be higher that normal. Creatine kinase is the enzyme that is released when muscles are damaged. Its presence in the blood of an individual is a likely indication that the patient is suffering from rhabdomyolysis

Urine Sample

A urine sample of the patient was also collected and taken to the lab for testing. During collection, the color of the urine was noted. Urinalysis was done on the urine. The urine of the patient was dark orange in color. It was concentrated. Casts and hemoglobin were present on the urine without red blood cells on investigation under the microscope.

Although the above test are essential in the diagnosis of rhabdomyolysis, they were not done on this particular patient since the results from the biopsy, blood and urine tests were sufficient enough to diagnose the patient with the condition.

Plan of care

From the results that were obtained from the tests that were conducted, the patient was diagnosed with rhabdomyolysis and acute renal failure. To ensure full recovery several adjustments had to be made. These adjustments aimed at giving him proper medicine for his condition and adjusting his behavior, diet and lifestyle. This mainly included the termination of using specific drugs and the reduction of alcohol consumption.

The consumption of alcohol was prohibited. His HIV medication shall be put on halt. He was given diuresis. Dialysis begun on the second day after the patient was admitted. The use of alcohol was prohibited as due to his HIV condition, rhabdomyolysis and renal failure. The use of HIV drugs and other medications may have contributed greatly to the development of renal failure. Diuresis and dialysis were administered to stabilize his condition.

Through rest and constant medicine the levels of creatine kinase were expected to reduce drastically with time. The highest level of creatine kinase was on day four when it was greater than 70,000 U/L. By the time the patient was discharged (2 weeks later), the level of creatine kinase was 1650 U/L. The increase of creatine kinase during the early days of medication was as a result of the administration of the drugs. However, once they took effect, its levels started to decline drastically.

Having stabilized the condition, the patient re-embarked on his HIV medication. He was however not administered with statins. The patient was also weak but after a while, he recovered his strength fully. The patient re-embarked on his HIV medication after six weeks. This was a time when his condition had stabilized. The use of statins was however stopped due to his renal infection.

References

Domino, F. (2011). The 5-Minute Clinical Consult 2011. New York: Lippincott Williams & Wilkins.

Howard, J., & Thorson, M. (2008). Society of trauma Nurses position statement on the role of the clinical nurses specialist in trauma. Journal of trauma nursing, 15(9), 91-93.

Johns, C., & Freshwater, D. (2006). Transforming nursing through reflective practice. Journal of Advanced Nursing, 21(5), 123-137.

Mildon, B., & Underwood, J. (2010). Competencies for home health Nursing: A literature review prepared for the community health nurses of Canada. Community health nurses of Canada, 3-31.

Poels, P.J. (1993). Rhabdomyolysis: some clinical and etiological aspects and prevention by dantrolene sodium. London: Sage.

Wolfson, A. (2009). Harwood-Nuss’ clinical practice of emergency medicine. New York: Lippincott Williams & Wilkins.

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