Case Scenario 1

You are working in the internal medicine clinic of a large teaching hospital. Today
your first patient is 70-year-old J.M., a man who has been coming to the hospital for
several years for management of coronary artery disease (CAD) and hypertension
(HTN). A cardiac catheterization done a year ago showed 50% stenosis of the
circumflex coronary artery. He has had episodes of dizziness for the past 6 months
and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance
for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR)
showed cardiomegaly, and a 12-lead electrocardiogram (ECG) showed sinus
tachycardia with left bundle branch block (LBBB). You review his morning blood work
and initial assessment.
Chart review
Laboratory Testing
Chemistry
Sodium 142 mEq/L
Chloride 95 mEq/L
Potassium 3.9 mEq/L
Creatinine 0.8 mg/dL
Glucose 82 mg/dL
BUN 19 mg/dL
CBC
WBC 5400/mm 3
Hgb 13 g/dL
Hct 41%
Platelets 229,000/mm 3
Initial Assessment
Complains of increased fatigue and shortness of breath, especially with
activity, and “waking up gasping for breath” at night, for the past 2 days.
Vital Signs
Temperature 97.9° F (36.6° C)
Blood pressure 142/83 mm Hg
Heart rate 105 beats/min
Respiratory rate 18 breaths/min
J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs
to his bedroom and has to lie down and rest (“put my feet up”) at least an hour
twice a day. He has been sleeping on two pillows for the past 2 weeks. He has not
salted his food since the physician told him not to because of his high blood
pressure, but he admits having had ham and a whole bag of salted peanuts 3 days
ago. He denies having palpitations but has had a constant, irritating, nonproductive
cough lately
Chart review
Medication Orders
Enalapril (Vasotec) 10 mg PO twice a day
Furosemide (Lasix) 20 mg PO every morning
Carvedilol (Coreg) 6.25 mg PO twice a day
Digoxin (Lanoxin) 0.5 mg PO now, then 0.125 mg PO daily
 Potassium chloride 10 mEq tablet PO once a day
Case scenario 2
You are assigned to care for L.J., a 70-year-old retired bus driver who has just been
admitted to your medical floor with right leg deep vein thrombosis (DVT). L.J. has a
48-pack-year smoking history, although he states he quit 2 years ago. He has had
pneumonia several times and frequent episodes of atrial flutter/ fibrillation. He has
had two previous episodes of DVT and was diagnosed with rheumatoid arthritis 3
years ago. Two months ago. he began experiencing shortness of breath on exertion
and noticed swelling of his right lower leg that became progressively worse until it
extended up to his groin. His wife brought him to the hospital when he complained
of increasingly severe pain in his leg. When a Doppler study indicated a probable
thrombus of the external iliac vein extending distally to the lower leg, he was
admitted for bed rest and to initiate heparin therapy. His basic metabolic panel was
normal; other laboratory results are listed as follows:
Chart View
Laboratory Testing
PT 12.4 sec
INR 1.11
aPTT 25 sec
Hgb 13.3 g/dL
Hct 38.9%
Cholesterol 206 mg/dL
Your assessment of L.J. reveals bibasilar crackles with moist cough; normal heart
sounds; blood pressure (BP) 138/88 mm Hg; pulse 104 beats/min; 3+ pitting edema
of right lower extremity; mild erythema of right foot and calf; and severe right calf
pain. He is awake, alert, and oriented but a little restless. His Sao2 is 92% on room
air. He denies chest pain but does have shortness of breath with exertion.
L.J. is placed on 72-hour bed rest with bathroom privileges and given
acetaminophen (Tylenol) for pain. The physician also writes orders for enoxaparin
(Lovenox) injections.
Case Scenario 3
The wife of C.W., a 70-year-old man, brought him to the emergency department
(ED) at 4:30 this morning. She told the ED triage nurse that he had had dysentery
for the past 3 days, and, last night, he had a lot of “dark red” diarrhea. When he
became very dizzy, disoriented, and weak this morning, she decided to bring him to
the hospital. C.W.'s vital signs (VS) were 70/- (systolic blood pressure [BP] 70mm Hg,
diastolic BP inaudible), 110, 20, 99.1° F (37.3° C). A 16-gauge IV catheter was
inserted, and a lactated Ringer's (LR) infusion was started. The triage nurse
obtained the following history from the patient and his wife. C.W. has had idiopathic
dilated cardiomyopathy for several years. The onset was insidious, but the
cardiomyopathy is now severe, as evidenced by an ejection fraction (EF) of 13%
found during a recent cardiac catheterization. He experiences frequent problems
with heart failure (HF) because of the cardiomyopathy. Two years ago, he had a
cardiac arrest that was attributed to hypokalemia. He also has a long history of
hypertension (HTN) and arthritis. He has also had atrial fibrillation in the past, but it
has been under control recently. Fifteen years ago, he had a peptic ulcer. An
endoscopy showed a 25 × 15mm duodenal ulcer with adherent clot. The ulcer was
cauterized, and C.W. was admitted to the medical intensive care unit (MICU) for
treatment of his volume deficit. You are his admitting nurse. As you are making him
comfortable, Mrs. W. gives you a paper sack filled with the bottles of medications he
has been taking: enalapril (Vasotec) 5mg PO bid, warfarin (Coumadin) 5mg/day PO,
digoxin (Lanoxin) 0.125mg/day, PO, potassium chloride 20mEq PO bid, and
diclofenac sodium (Voltaren) 50mg PO tid. As you connect him to the cardiac
monitor, you note that he is in sinus tachycardia. Doing a quick assessment, you
find a pale man who is sleepy but arousable and oriented. He is still dizzy,
hypotensive, and tachycardic. You hear S3 and S4 heart sounds and a grade II/VI
systolic murmur. Peripheral pulses are all 2+, and trace pedal edema is present.
Lungs are clear. Bowel sounds are present, mid epigastric tenderness is noted, and
the liver margin is 4cm below the costal margin. A Swan-Ganz catheter and an
arterial line are inserted
C.W. receives a total of 4 units of packed red blood cells (PRBCs), 5 units of fresh
frozen plasma (FFP), and several liters of crystalloids to keep his mean BP above 60
mm Hg. On the second day in the MICU, his total fluid intake is 8.498 L and output is
3.66 L for a positive fluid balance of 4.838 L. His hemodynamic parameters after
fluid resuscitation are pulmonary capillary wedge pressure (PCWP) 30 mm Hg and
cardiac output (CO) 4.5 L/min.

Chart View
Lab Work
Sodium 138 mEq/L
Potassium 6.9 mEq/L
BUN 90 mg/dL
Creatinine 2.1 mg/dL
WBC 16,000/mm 3
Hgb 8.4 g/dL
Hct 25%
PT 23.4 seconds
INR 4.2

ECG tracing
Case Scenario 4
J.F. is a 50-year-old married homemaker with a genetic autoimmune deficiency; she
has suffered from recurrent infective endocarditis. The most recent episodes were a
Staphylococcus aureus infection of the mitral valve 16 months ago and a
Streptococcus viridans infection of the aortic valve 1 month ago. During this latter
hospitalization, an echocardiogram showed moderate aortic stenosis, moderate
aortic insufficiency, chronic valvular vegetations, and moderate left atrial
enlargement. Two years ago, J.F. received an 18-month course of parenteral
nutrition for malnutrition caused by idiopathic, relentless nausea and vomiting
(N/V). She has also had coronary artery disease for several years and, 2 years ago,
suffered an acute anterior wall myocardial infarction (MI). In addition, she has a
history of chronic joint pain. Now, after being home for only a week, J.F. has been
readmitted to your floor with endocarditis, N/V, and renal failure. Since yesterday,
she has been vomiting and retching constantly; she also has had chills, fever,
fatigue, joint pain, and headache. As you go through the admission process with
her, you note that she wears glasses and has a dental bridge. Intravenous access is
obtained with a double lumen peripherally inserted central catheter (PICC) line, and
other orders are written below. Your assessment is also documented.

Chart View
Admission Orders
STAT blood cultures (aerobic and anaerobic) × 2
STAT electrolytes & CBC
Begin parenteral nutrition (PN) at 85 mL/hr
Penicillin 2 million units IV piggyback q4h
Furosemide (Lasix) 80 mg/day PO
Amlodipine (Norvasc) 5 mg/day PO
Potassium chloride (K-Dur) 40 mEq/day PO
Metoprolol (Lopressor) 25 mg PO bid
Prochlorperazine (Compazine) 5 mg IV push prn for N/V
Transesophageal echocardiogram ASAP
Admission Assessment
Blood pressure 152/48 (supine) and 100/40 (sitting)
Pulse rate 116 beats/min
Respiratory rate 22 breaths/min
Temperature 37.9° C
Oriented × 3 but drowsy
Grade II/VI holosystolic murmur and a grade III/VI diastolic murmur noted on
auscultation
Lungs clear bilaterally
Abdomen soft with slight left upper quadrant (LUQ) tenderness
 Multiple petechiae on skin of arms, legs, and chest; and splinter
hemorrhages under the
fingernails
Hematuria noted in voided urine

Laboratory Test Results

Na 138 mEq/L
K 3.9 mEq/L
Cl 103 mEq/L
BUN 85 mg/dL
Creatinine 3.9 mg/dL
Glucose 165 mg/dL
WBC 6700/mm 3
Hct 27%
Hgb 9.0 g/dL
Case Scenario 5
A.W., a 52-year-old woman disabled from severe emphysema, was walking at a mall
when she suddenly grabbed her right side and gasped, “Oh, something just
popped.” A.W. whispered to her walking companion, “I can't get any air.” Her
companion yelled for someone to call 911 and helped her to the nearest bench. By
the time the rescue unit arrived, A.W. was stuporous and in severe respiratory
distress. She was intubated, an IV of lactated Ringer's (LR) to KVO (keep vein open)
was started, and she was transported to the nearest emergency department (ED).
On arrival at the ED, the physician auscultates muffled heart tones, no breath
sounds on the right, and faint sounds on the left. A.W. is stuporous, tachycardic, and
cyanotic. The paramedics inform the physician that it was difficult to ventilate A.W.
A portable chest x-ray (CXR) shows an 80% pneumothorax on the right
Chart View
Arterial Blood Gases (100% O2)
pH 7.25
PaCO2 92 mm Hg
PaO2 32 mm Hg
HCO3 27 mmol/L
SaO2 53%
Because A.W. has a history of spontaneous pneumothoraxes on the right side, the
physician suggests performing chemical pleurodesis
Case Scenario 6
S.P. is admitted to the orthopedic ward. She has fallen at home and has sustained
an intracapsular fracture of the hip at the femoral neck. The following history is
obtained from her: She is a 75-year-old widow with three children living nearby. Her
father died of cancer at age 62; mother died of heart failure at age 79. Her height is
5 feet 3 inches; weight is 118 pounds. She has a 50-pack-year smoking history and
denies alcohol use. She has severe rheumatoid arthritis (RA), had an upper
gastrointestinal bleed in 1993, and had coronary artery disease with a coronary
artery bypass graft 9 months ago. Since that time she has engaged in “very mild
exercises at home.” Vital signs (VS) are 128/60, 98, 14, 99° F (37.2° C), Sa o2 94%
on 2 L oxygen by nasal cannula. Her oral medications are rabeprazole (Aciphex) 20
mg/day, prednisone (Deltasone) 5 mg/day, and methotrexate (Amethopterin) 2.5
mg/wk.
S.P. is taken to surgery for a total hip replacement. Because of the intracapsular
location of the fracture, the surgeon chooses to perform an arthroplasty rather than
internal fixation. The postoperative orders include:
Chart review
Physician's Orders
• Cefazolin (Kefzol) 1000 mg IV q8h × 3 doses
• Enoxaparin (Lovenox) 30 mg subcut q12h
• Warfarin (Coumadin) 2.5 mg × 3 days, starting postoperative day 1, then titrated
to INR
• Docusate and senna (Peri-Colace) 1 capsule PO bid
• Multivitamin with iron (Trinsicon) 1 capsule/day PO with meals
 CBC in morning after blood reinfusion
• Hydromorphone (Dilaudid) by IV patient-controlled analgesia, intermittent with
0.1 mg
dosing, lockout 10 minutes
• PT and OT to evaluate on postoperative day 1 and start therapy
• Ketorolac (Toradol) 15 mg IV q6h prn pain × 5 days only
• Hip precautions per protocol
• Ondansetron (Zofran) 4 mg IV q6h prn for nausea
• Toilet seat extension
• Straight catheterization if no void by 8 hours postoperatively
Case Scenario 7
H.K. is a 26-year-old man who tried to light a cigarette while driving and lost control
of his truck. The truck flipped and landed on the passenger side. H.K. was
transported to the emergency department with a deformed, edematous right lower
leg and a deep puncture wound approximately 5cm long over the deformity. Blood
continues to ooze from the wound.
H.K. is taken to surgery for open reduction and internal fixation (ORIF) of the tibia
and fibula fractures. He returns with a full-leg fiberglass cast with windows over the
areas of surgery.
CASE STUDY PROGRESS
H.K. returns to surgery. The wound over H.K.'s fracture site has become necrotic
with purulent drainage. The wound is debrided and cultured; then a posterior splint
is applied. H.K. returns to his room with orders for wet-to-moist dressing changes.
The physician suspects osteomyelitis and orders nafcillin (Unipen) and ciprofloxacin
(Cipro). Contact precautions are implemented
Case Scenario 8
Scenario M.M., a 76-year-old retired schoolteacher, underwent open reduction and
internal fixation (ORIF) for a fracture of his right femur. His preoperative control
prothrombin time (PT/INR) was 11 sec/1.0 and his aPTT was 35 seconds. He has
been on bed rest for the first 2 days postoperatively. At 0600, his vital signs were
132/84, 80 with regular rhythm, 18 unlabored, and 99° F (37.2° C). He is awake,
alert, and oriented with no adventitious heart sounds. Breath sounds are clear but
diminished in the bases bilaterally. Bowel sounds are present, and he is taking sips
of clear liquids. An IV of D5½NS is infusing 75mL/hr in his left hand and orders are
to change it to a saline lock in the morning if he is able to maintain adequate PO
fluid intake. He has orders for oxygen (O2 ) to maintain Sao2 over 92%. His lab work
shows Hct, 34%; Hgb, 11.3mg/dL; K, 4.1mEq/L; aPTT, 44 sec. Pain is controlled with
morphine sulfate 4mg IV as needed every 4 hours, and he has promethazine
(Phenergan) 25mg IV q3h if needed for nausea. He is also receiving heparin 5000
units subcutaneously bid, taking docusate sodium (Colace) PO once daily, and
wearing a nitroglycerin patch. At 2330 on the second postoperative day, you answer
M.M.'s call light and find him lying in bed breathing rapidly and rubbing the right
side of his chest. He is complaining of right-sided chest pain and appears to be
restless.

You check his vital signs, with these results: BP 98/60; P 120; R 24. In addition, you
note that he is restless and slightly confused. The pulse oximeter reads 86%, so you
start him on 6 L O2 by nasal cannula. You identify faint crackles in the posterior
bases bilaterally; you recall that the lungs were clear this morning. The heart
monitor on lead II shows nonspecific T-wave changes.

You evaluate the room air ABG results:

Chart View
Arterial Blood Gases
pH 7.55
Pa CO2 24 mm Hg
HCO 3 24 mEq/L
Pa O2 56 mm Hg
Sa O2 86% (room air)
Vital Signs
Blood pressure 150/92 mm Hg
Heart rate 110 beats/min
Respiratory rate 28 breaths/min
Temperature 37.2° C
The chest x-ray showed a small right infiltrate. The physician suspects an embolism,
either fat or pulmonary, and orders a STAT ventilation/perfusion (V/Q ) lung scan.
The interpretation of the results reads “strongly suggestive of a pulmonary embolus
(PE).”
The physician decides not to administer an antidote, and M.M. is monitored closely.
Four hours later, the aPTT is 40 seconds.

Case Scenario 9
J.G., a 49-year-old man, was seen in the emergency department (ED) 2 days ago,
diagnosed with alcohol intoxication, and released after 8 hours to his brother's care.
He was brought back to the ED 12 hours ago with an active gastrointestinal (GI)
bleed and is being admitted to the intensive care unit (ICU); his diagnosis is upper
GI bleed and alcohol intoxication. You are assigned to admit and care for J.G. for the
remainder of your shift. According to the ED notes, his admission vital signs were BP
84/56 mm Hg, P 110 bpm, R 26, and he was vomiting bright red blood. He was
given IV fluids and transfused 6 units of packed red blood cells (PRBCs) in the ED.
On initial assessment, you note that J.G.'s VS are blood pressure BP 154/90 mm Hg,
P 110 bpm; he has a slight tremor in his hands, and he appears anxious. He
complains of a headache and appears flushed. You note that he has not had any
emesis and has not had any frank red blood in his stool or melena (black tarry
stools) over the past 5 hours. In response to your questions, J.G. denies that he has
an alcohol problem but later admits to drinking approximately a fifth of vodka daily
for the past 2 months. He reports that he was drinking San Miquel (Gin) just before
his admission to the ED. He admits to having had seizures while withdrawing from
alcohol in the past.

Chart View
Admission Lab Work
Hgb 10.9 g/dL
Hct 23%
ALT (SGPT) 69 units/L
AST (SGOT) 111 units/L
GGT 75 units/L
Serum alcohol (ETOH) 291 mg/dL
Case Scenario 10
You are a nurse on an inpatient psychiatric unit. J.M., a 23-year-old woman, was
admitted to the psychiatric unit last night after assessment and treatment at a local
hospital emergency department (ED) for “blacking out at school.” She has been
given a preliminary diagnosis of anorexia nervosa. As you begin to assess her, you
notice that she has very loose clothing, she is wrapped in a blanket, and her
extremities are very thin. She tells you, “I don't know why I'm here. They're making
a big deal about nothing.” She appears to be extremely thin and pale, with dry and
brittle hair, which is very thin and patchy, and she constantly complains about being
cold. As you ask questions pertaining to weight and nutrition, she becomes
defensive and vague, but she does admit to losing “some” weight after an
appendectomy 2 years ago. She tells you that she used to be fat, but after her
surgery she didn't feel like eating and everybody started commenting on how good
she was beginning to look, so she just quit eating for a while. She informs you that
she is eating lots now, even though everyone keeps “bugging me about my weight
and how much I eat.” She eventually admits to a weight loss of “about 40 pounds
and I'm still fat.”
You review her admission laboratory studies. An ECG has also been ordered.
Chart View
Admission Lab Work
Sodium 135 mEq/L
Potassium 3.4 mEq/L
Chloride 99 mEq/L
BUN 18 mg/dL
Creatinine 1.0 mg/dL
Hemoglobin 11 g/dL
Hematocrit 35%