CASE STUDY FOR MEDICAL SURGICAL NURSING: (PART 2)

Myocardial Infarction

A 66-year-old man sought medical care at the hospital due to severe chest
pain lasting for 24 hours. The patient was aware of being hypertensive and
was a smoker. Without any prior symptom, he started to have severe chest
pain and sought emergency medical care after about 24 hours, due to pain
persistence.

At physical examination (August 13, 2005, 10 PM) he had a heart rate of 90

bpm and blood pressure of 110/70 mmHg. Lung examination showed no
alterations. Heart assessment showed a systolic murmur in the lower left
sternal border and mitral area.

The initial electrocardiogram (August 13, 2005, 22 h) showed HR of 100

bpm, sinus rhythm, 1st-degree atrioventricular block (PR 240 ms), low-
voltage QRS complexes in the frontal plane, QRS complex electrical
alternans and extensive ongoing anterior wall infarction (QS V1 to V6, ST
elevation in the same leads and QS in the inferior wall, II, III and aVF)
(Figure 1).
Acetylsalicylic acid by oral route and 5 mg of intravenous metoprolol were
administered. The patient had bradycardia and cardiorespiratory arrest in
pulseless electrical activity, reversed after five minutes. He developed
hypotension and peripheral hypoperfusion and was transferred to InCor
(The Heart Institute).

On admission he had received heparin and continuous intravenous

norepinephrine. BP was 60/30 mmHg.

The ECG (August 13, 2005, 11:36 PM) disclosed heart rate of 116 bpm,
junctional escape rhythm with sinus arrest and atrial extrasystoles); low-
voltage QRS complex in the frontal plane, extensive ongoing anterior acute
myocardial infarction, inactive area in the inferior wall; presence of ST
elevation at V1 to V5 and ST depression in leads I, II and aVF; ST
elevation in aVR (Figure 2).

Coronary angiography was indicated, which disclosed anterior

interventricular branch occlusion and images suggestive of intracoronary
thrombus, lesion of 70% in the circumflex artery, 50% in the right coronary
artery and 70% in the ostium of the right posterior descending branch.

REFERENCE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193075/
Addison’s Disease

Patient Characteristics

Demographics: 21 year old Caucasian male, part time package handler

at UPS

Co-morbidities: Type 1 Diabetes

Previous care: Patient has had previous physical therapy for an ACL
repair after an injury playing soccer in 2010.

Examination

Subjective: Jack E. Robinson, a 21 year old Caucasian male who lives

with his parents, reports to your clinic with a chief complaint of gradual
onset of weakness and fatigue, and pain in his knees. On a 0-10 scale,
he states that the pain in his knees is at a 3/10 at best and a 6/10 at its
worst. Jack works at United Parcel Service (UPS) at night while
attending the local community college during the day. His work duties
require him to lift boxes up to 60 lbs. by himself and he has been
struggling to do so in recent months, even becoming dizzy and nearly
fainting a few times. He has used almost all of his sick days due to
feeling nauseous and vomiting while at work and occasionally before
coming to work. He reported a slight decrease in his weight and not
being hungry nearly as often. He used to stop by the 24 hour Subway for
a sandwich every night after work, but only goes one or two times per
week in recent months. Now when he goes the sandwiches taste bland
and he has to use a lot of salt to make them taste better. He states
being nervous about eating certain foods when he is hungry due to
diarrhea which he has not figured out the cause of. When asked, he
states that his tanned skin from the summer has not faded like it usually
does even though it is well into the winter months (January) and that he
does not use a tanning bed. He states his parents are worried because
he is quick to become irritated with them and rarely comes out of his
room when at home.
Services: Jack has seen his primary care physician twice since the
onset of symptoms and last time was referred to PT with a prescription
that said “evaluate and treat for weakness and fatigue”. He has received
no other care for his current condition.

Patient Goals: increase strength and stamina in order to return to peak

performance levels at work and so that workout regimen can resume.

Self-Report Outcome Measures: ODI, FABQ, SANE

Physical Performance Measures: 6 minute walk test, 10 time STS

Objective:

Vitals:

HR: 78
BP: 106/54
RR: 16

ROM:

All ROM within normal limits

MMT:
Shoulder Flexion: 4+/5
Shoulder Ext: 4+/5
Shoulder Abd: 4/5
Shoulder IR: 4/5
Shoulder ER: 4/5
Elbow Flex: 4+/5
Elbow Ext: 4+/5
Hip Flex: 4+/5
Hip Ext: 4-/5
Hip Abd: 4-/5
Hip Add: 4+/5
Hip IR: 4/5
Hip ER: 4-/5
Knee Flex: 4+/5 painful
Knee Ext: 4+/5 painful
All other MMT WNL

Sensation/Reflexes:
All WNL

Observation:

Knee joint pain with palpation and passive motion

Abnormally tan skin

[6]

Clinical Impression

Based on the information gathered from the subjective and objective

history, the primary hypothesis would be that this patient is suffering
from Addison’s disease. The patient complained of unusual fatigue,
weakness, frequent diarrhea, a craving of salty foods, decreased
appetite, joint pain, and that his tan was lasting longer than usual. [1][2][3]
[4]
Accompanied by objective findings of generalized muscle weakness,
low blood sugar, hyperpigmentation of multiple areas of skin, and painful
joints during palpation, Addison’s disease would be the most probable
diagnosis.[1][2][3][4] We believe this patient would need to be referred to a
medical doctor to confirm the presence of Addison's disease and for
other treatment outside the scope of physical therapy. [1][2] This being
said, this patient would be a great candidate for physical therapy and
would benefit from a muscular strengthening and endurance program.
[7]

Summarization of Examination Findings

Patient displays generalized muscle weakness, weight loss due to a

decrease in appetite, joint pain with palpation and movement, salt
cravings, nausea, diarrhea, vomiting, and dizziness. Aerobic exercise
will be implemented to address generalized weakness and fatigue. A
strengthening program will also be implemented to address the
generalized muscle weakness and fatigue.

REFERENCE: https://www.physio-pedia.com/Addison
%27s_Disease_Case_Study

ONCOLOGIC NURSING

Case Overview: A 72-Year-Old Woman With Metastatic Colorectal

Cancer

May 2018

Initial presentation

A 72-year-old woman reported a 2-month history of bloating and abdominal

cramping, and an 8-pound unintentional weight loss
Her last screening colonoscopy when she was 70 years of age was
negative

PMH: hysterectomy at age 60, high blood pressure well controlled with
lisinopril

Clinical workup

Labs: Hg 8.4 g/dL, CEA 6 ng/mL

Colonoscopy revealed a 9-cm mass in ascending colon

Pathology: invasive, poorly differentiated adenocarcinoma

Molecular testing: KRAS, NRAS, and BRAF wildtype; microsatellite stable

CT scan revealed widespread lesions in the liver

Diagnosis: Stage 4 colorectal cancer

ECOG PS is 1

Treatment

The patient received systemic therapy with FOLFOX + bevacizumab for 6

cycles, which was well tolerated

Follow-up imaging at 2 months and 4 months showed response in liver

lesions

The patient continued on bevacizumab maintenance

June 2019

 The patient presents with shortness of breath and fatigue

 CT CAP shows two new lung lesions and growth of liver lesions
 The patient is switched to FOLFIRI and cetuximab
 Follow-up imaging showed stable disease in liver and lungs

August 2020

 The patient reports severe fatigue

  CT CAP shows progression in the lungs and new bony lesions
 The patient is given regorafenib alone

Chronic Obstructive Pulmonary Disease

The patient is a 60-year-old white female presenting to the emergency
department with acute onset shortness of breath. Symptoms began
approximately 2 days before and had progressively worsened with no
associated, aggravating, or relieving factors noted. She had similar
symptoms approximately 1 year ago with an acute, chronic obstructive
pulmonary disease (COPD) exacerbation requiring hospitalization. She
uses BiPAP ventilatory support at night when sleeping and has requested
to use this in the emergency department due to shortness of breath and
wanting to sleep.
She denies fever, chills, cough, wheezing, sputum production, chest pain,
palpitations, pressure, abdominal pain, abdominal distension, nausea,
vomiting, and diarrhea.
She reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling
chilled, requiring blankets, increased urinary frequency, incontinence, and
swelling in her bilateral lower extremities that are new-onset and
worsening. Subsequently, she has not ambulated from bed for several days
except to use the restroom due to feeling weak, fatigued, and short of
breath.
There are no known ill contacts at home. Her family history includes
significant heart disease and prostate malignancy in her father. Social
history is positive for smoking tobacco use at 30 pack years. She quit
smoking 2 years ago due to increasing shortness of breath. She denies all
alcohol and illegal drug use. There are no known foods, drugs, or
environmental allergies.
Past medical history is significant for coronary artery disease, myocardial
infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes
mellitus, peripheral vascular disease, tobacco usage, and obesity. Past
surgical history is significant for an appendectomy, cardiac catheterization
with stent placement, hysterectomy, and nephrectomy.
Her current medications include fluticasone-vilanterol 100-25 mcg inhaled
daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide 25
mg by mouth daily, albuterol-ipratropium inhaled every 4 hours PRN,
levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice
per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily,
vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily,
isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by
mouth daily.
Physical Exam
Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm,
respiratory rate 24, BP 104/54, HT 160 cm, WT 100 kg, BMI 39.1, and O2
saturation 90% on room air.
Constitutional: Extremely obese, acutely ill-appearing female. Well-
developed and well-nourished with BiPAP in place. Lying on a hospital
stretcher under 3 blankets.
HEENT:
 Head: Normocephalic and atraumatic
 Mouth: Moist mucous membranes
 Macroglossia
 Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and
reactive to light. No scleral icterus. Bilateral periorbital edema
present.
 Neck: Neck supple. No JVD present. No masses or surgical scarring.
 Throat: Patent and moist
Cardiovascular: Normal rate, regular rhythm, and normal heart sound with
no murmur. 2+ pitting edema bilateral lower extremities and strong pulses
in all four extremities.
Pulmonary/Chest: No respiratory status distress at this time, tachypnea
present, (+) wheezing noted, bilateral rhonchi, decreased air movement
bilaterally. The patient was barely able to finish a full sentence due to
shortness of breath.
Abdominal: Soft. Obese. Bowel sounds are normal. No distension and no
tenderness
Skin: Skin is very dry
Neurologic: Alert, awake, able to protect her airway. Moving all
extremities. No sensation losses
Go to:

Initial Evaluation
Initial evaluation to elucidate the source of dyspnea was performed and
included CBC to establish if an infectious or anemic source was present,
CMP to review electrolyte balance and review renal function, and arterial
blood gas to determine the PO2 for hypoxia and any major acid-base
derangement, creatinine kinase and troponin I to evaluate the presence of
myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and
chest x-ray. Considering that it is winter and influenza is endemic in the
community, a rapid influenza assay was obtained as well.
CBC
Largely unremarkable and non-contributory to establish a diagnosis.
CMP
Showed creatinine elevation above baseline from 1.08 base to 1.81,
indicating possible acute injury. EGFR at 28 is consistent with chronic renal
disease. Calcium was elevated to 10.2. However, when corrected for
albumin, this corrected to 9.8 mg/dL. Mild transaminitis is present as seen
in alkaline phosphatase, AST, and ALT measurements which could be due
to liver congestion from volume overload.
Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6,
and oxygen saturation 90% on room air, indicating respiratory alkalosis with
hypoxic respiratory features.
Creatinine kinase was elevated along with serial elevated troponin I
studies. In the setting of her known chronic renal failure and acute injury
indicated by the above creatinine value, a differential of rhabdomyolysis is
determined.
Influenza A and B: Negative
ECG
Normal sinus rhythm with non-specific ST changes in inferior leads.
Decreased voltage in leads I, III, aVR, aVL, aVF.
Chest X-ray
Findings: Bibasilar airspace disease that may represent alveolar edema.
Cardiomegaly noted. Prominent interstitial markings were noted. Small
bilateral pleural effusions
Radiologist Impression: Radiographic changes of congestive failure with
bilateral pleural effusions greater on the left compared to the right
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Differential Diagnosis
 Acute on chronic COPD exacerbation
 Acute on chronic renal failure
 Bacterial pneumonia
 Congestive heart failure
 NSTEMI
 Pericardial effusion
 Hypothyroidism
 Influenza pneumonia
 Pulmonary edema
 Pulmonary embolism
Go to:

Confirmatory Evaluation
On the second day of the admission patient’s shortness of breath was not
improved, and she was more confused with difficulty arousing on
conversation and examination. To further elucidate the etiology of her
shortness of breath and confusion, the patient's husband provided further
history. He revealed that she is poorly compliant with taking her
medications. He reports that she “doesn’t see the need to take so many
pills.”
Testing was performed to include TSH, free T4, BNP, repeated arterial
blood gas, CT scan of the chest, and echocardiogram. TSH and free T4
evaluate hypothyroidism. BNP evaluates fluid load status and possible
congestive heart failure. CT scan of the chest will look for anatomical
abnormalities. An echocardiogram is used to evaluate left ventricular
ejection fraction, right ventricular function, pulmonary artery pressure,
valvular function, pericardial effusion, and any hypokinetic area.
 TSH: 112.717 (H)
 Free T4: 0.56 (L)
 TSH and Free T4 values indicate severe primary hypothyroidism.
 BNP: 187

Diagnosis
1. Myxedema coma or severe hypothyroidism
2. Pericardial effusion secondary to myxedema coma
3. COPD exacerbation
4. Acute on chronic hypoxic respiratory failure
5. Acute respiratory alkalosis
6. Bilateral community-acquired pneumonia
7. Small bilateral pleural effusions
8. Acute mild rhabdomyolysis
9. Acute chronic, stage IV, renal failure
10. Elevated troponin I levels, likely secondary to Renal failure
11. Diabetes mellitus type 2, non-insulin-dependent
12. Extreme obesity
13. Hepatic dysfunction