CARDIO CASE SCENARIO # 1

Day 1: September 14, 2021 @ 7:00 am

Patient X is a 56-year-old male who came to a private hospital in Tarlac with a chief
complaint of crushing substernal chest pain radiating at left arm, he rated 8/10. He is also
nauseated and diaphoretic. His vital signs were BP 150/90, RR 24 HR 90, RR 22 SpO2
89%, and temperature 36.9 degree Celsius. Chest X ray revealed clear lung sounds, mild
tachypnea, S1 S2 present, and several ulcerations to the right foot. Diagnostic and
laboratory tests were given to obtain a 12-lead ECG and labs (CBC, CMP, Coagulations,
Cardiac Enzymes, and Lipid Profile). In addition, oxygen support via nasal cannula of 2
liters per minute was given and venous access was initiated with a 20 gauge IV at his left
antecubital area.

Patient X medical history revealed that he is a type II diabetic, has hypertension,

hyperlipidemia, and smokes 1/2 pack of cigarettes a day for the past 40 years. His
diabetes is poorly managed and had a left below the knee amputation 2 years ago due to
diabetic ulcers that were gangrenous. In addition, Patient X has a history of IV drug use
but now receives a daily dose (90 mg) of Methadone at a local clinic.

Day 2: His ECG results showed ST-segment elevation in leads II, III, and ventricular
fibrillation in V4, V5 and V6 with ST-segment depression V1, V2, and V3. The provider
identified this to be an MI occurring in the inferior portion of the heart, likely affecting his
right coronary artery (RCA). Laboratory results confirmed a ST-segment elevation MI
(Troponin-I 12.9, CK 520, and CKMB 25.2). He was prepared then for a Percutaneous
coronary intervention (PCI). While waiting for the special procedure, he was given 325
mg of Aspirin, 2 mg Morphine, and was started on a 5000-unit bolus of Heparin.
Nitroglycerin was not given due to the profound hypotension associated with nitroglycerin
and patients experiencing an inferior myocardial infarction.

Upon transfer to the treatment room, his vital signs were stable and he was able to give
informed consent. The cardiac angiography showed a 95% occlusion of the RCA. A stent
was placed, the patient tolerated the procedure well. The patient’s right femoral artery
was closed successfully with manual pressure.

Patient X returned to the cardiac care unit where upon assessment his groin was found
to be soft and without hematoma and with minimal drainage from incision site. His
peripheral pulses were present, and distal to the incision his skin was warm with capillary
refill less than 2 seconds.

Before discharge, new prescriptions of medications were given and health teachings on
the importance of taking his daily aspirin. He met his Endocrinology physician, dietician,
and social worker for Counselling before discharge. He was informed to start cardiac
rehabilitation programs when he returned to his home.
CARDIO CASE SCENARIO # 2

Day 1: September 16, 2021 @ 10:00 am

Patient M, a 53 year-old male construction worker was brought to a District hospital at the
emergency department with a chief complaint of 20-minute episode of diaphoresis and
chest pain. The chest pain was central, radiating to the left arm and crushing in nature.
The pain settled promptly following 300 mg aspirin orally and 800 mcg glyceryl trinitrate
(GTN) spray sublingually administered by paramedics in the community. He smoked 20
cigarettes daily for 38 years but was not aware of any other cardiovascular risk factors.
On examination he appeared comfortable and was able to complete sentences fully.
There were no heart murmurs present on cardiac auscultation. Blood pressure was
180/105 mmHg, heart rate was 83 bpm and regular, oxygen saturation was 97%.

An ECG was requested on admission:

30 minutes later the patient's chest pain returned with greater intensity whilst waiting in
the emergency department. Now, he described the pain as though “an elephant is sitting
on his chest”. The nurse has already done an ECG by the time you were called to see
him.

ECG 30 minutes after admission:

Day 2: Patient M was taken to the catheterization lab where the left anterior descending
coronary artery (LAD) was shown to be completely occluded. Following successful
percutaneous intervention and one drug eluding stent implantation in the LAD normal flow
is restored. 72 hours later, he is ready to be discharged home. The patient is keen to
return to work and asks when he could do so.

Two days ago, he received a text message from his attending physician informing him
that he is required to attend cardiac rehabilitation. The patient is confused as to what
cardiac rehabilitation entails, although he does remember a nurse discussing this with
him briefly before he was discharged.

CARDIO CASE SCENARIO # 3

Day 1: September 21, 2021 @ 1:00 pm

Patient Y, a 65 year old female who is a retired nurse educator was brought in the
Emergency room accompanied by her son. She called her son after having symptoms of
shortness of breath and confusion. Her past medical history includes hypertension,
hyperlipidemia, coronary artery disease, and she was an everyday smoker for 30 years.
Her home medications are Captopril, Simvastatin, and Aspirin.

Upon admission, her initial vital signs include a blood pressure of 155/95, heart rate of
120, respiratory rate of 26, temperature of 37.0 degree Celsius and oxygen saturation of
84%. Her initial assessment included alert and oriented to person and place, dyspnea,
inspiratory crackles in bilateral lungs, and a cough with pink frothy sputum. Her laboratory
and diagnostics resulted in a Brain natriuretic peptide of 740 pg/ml, an echocardiogram
showing an ejection fraction of 35%, an ECG that read sinus tachycardia, and a chest X-
ray that confirmed pulmonary edema. Medical management were given such as
supplemental oxygen to keep saturation >93%, Furosemide IV, Enoxaparin
subcutaneous, and Metoprolol PO.

Day 2: Patient Y required 4L of oxygen via nasal cannula in order to maintain the goal
saturation of >93%. Auscultation of the lungs revealed bilateral crackles throughout,
requiring collaboration with respiratory therapy once in the morning, and once in the
afternoon. Physical therapy worked with the patient, but she was only able to ambulate
for 100 steps. During ambulation, the patient had a decrease of oxygen saturation and
dyspnea, requiring her oxygen to be increased to 6L. At the end of the day, strict intake
and output monitoring showed an intake of 1200 mL of fluids, with a urinary output of 2L.

Day 3: Patient Y began demonstrating signs of improvement. She only required 2 L of

oxygen via nasal cannula with diminished crackles heard upon auscultation. Morning
weight showed a weight loss of 1.3 lbs. and the patient was oriented to person, place,
and sequence of events. During physical therapy, she was able to ambulate 200 steps
without required increased oxygen support. Daily fluid intake was 1400 mL with a urinary
output of 1900 ml.
 On the fourth and final day of admission, Patient Y respiratory status did not require any
type of oxygen support. When physical therapy arrived, the patient was able to ambulate
300 steps. When the doctor arrived, the patient informed him that she felt so much better
and felt confident going home. The doctor placed orders for discharge.

Upon discharge, Patient Y was instructed to schedule a follow up appointment with her
Cardiologist for continued management of her care.
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DIRECTIONS:

1. Analyze the case scenario given, identify the disease/s being describe and the current
situation of the patient. Make use of your critical thinking through expanding your
knowledge for additional relevant data (additional clinical manifestations/presentations
you observed to your patient).

2. Interpret the abnormal laboratory and diagnostic results/findings.

3. Discuss the identified disease/s briefly through your Case analysis ------ (Per Group)

4. In each scenario, accomplish the following every clinical meeting:

▪ Daily PA -------- (Per group)

▪ Sample Charting ------ (Per student)
▪ NCP ------ (Per Student)
▪ Drug Study ------ (Per Student)
▪ Patient education (contents: Lifestyle, Activity/ Exercise, Diet, Follow – up check,
Psychological or Emotional or Spiritual Aspect of teaching needs) ------ (Per student)

“Acquiring knowledge is the most fruitful effort.” ― Eraldo Banovac

Prepared by: Bianca Camille M. Mercado, RN, MSN