Foundation University

College of Nursing
Dumaguete City

Case Scenario 1:

A 56-year-old man comes to the ER complaining of chest discomfort. He describes the discomfort as a
severe, retrosternal pressure sensation that had awakened him from sleep 3 hours earlier. He previously
had been well but has a medical history of hypercholesterolemia and a 40-pack-year history of smoking.
On examination, he appears uncomfortable and diaphoretic, with a heart rate of 116 bpm, blood pres-
sure of 166/102 mm Hg, respiratory rate of 22 breaths per minute, and oxygen sat-uration of 96% on
room air. Jugular venous pressure appears normal. Auscultation of the chest reveals clear lung fields, a
regular rhythm with an S4 gallop, and no murmurs or rubs. A chest radiograph shows clear lungs and a
normal cardiac silhouette. The electrocardiogram (ECG) is shown below.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 2:

A 72-year-old man complains of several weeks of worsening exertional dyspnea. He has experienced
angina-like chest pressure with strenuous exertion and nearsyncope while climbing a flight of stairs, and
now he has symptoms of heart failure such as orthopnea and paroxysmal nocturnal dyspnea. Heart
failure is also suggested by physical signs of volume overload (pedal edema, elevated jugular venous
pressure, and crackles suggesting pulmonary edema). The cause of his heart failure may be aortic
valvular stenosis, given the late systolic murmur radiating to his carotid, the paradoxical splitting of his
second heart sound, and the diminished carotid upstrokes.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 3:

A 26-year-old woman originally from Nigeria presents to the ER complaining of sudden onset of
palpitations and severe shortness of breath and coughing. She reports that she has experienced several
episodes of palpitations in the past, often lasting a day or two, but never with dyspnea like this. She has
a history of rheu-matic fever at the age of 14 years. She is now 20 weeks pregnant with her first child
and takes prenatal vitamins. She denies use of any other medications, tobacco, alcohol, or illicit
drugs.On examination, her heart rate is between 110 and 130 bpm and is irregularly irregular, with
blood pressure of 92/65 mm Hg, respiratory rate of 24 breaths per minute, and oxygen saturation of
94% on room air. She appears uncomfortable, with labored respirations. She is coughing, producing
scant amounts of frothy sputum with a pinkish tint. She has ruddy cheeks and a normal jugular venous
pressure. She has bilateral inspiratory crackles in the lower lung fields. On car-diac examination, her
heart rhythm is irregularly irregular with a loud S1 and low-pitched diastolic murmur at the apex. Her
apical impulse is nondisplaced. Her uterine fundus is palpable at the umbilicus, and she has no
peripheral edema. An ECG is obtained found below.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 4:

A 42-year-old man is brought to the ER by ambulance after a sudden onset of severe retrosternal chest
pain that began an hour ago while he was at home mowing the lawn. He describes the pain as sharp,
constant, and unrelated to movement. It was not relieved by three doses of sublingual nitroglycerin
admin-istered by the paramedics while en route to the hospital. He has never had symp-toms like this
before. His only medical history is hypertension, for which he takes enalapril. There is no cardiac disease
in his family. He does not smoke, drink alcohol, or use illicit drugs. He is a basketball coach at a local high
school, and is usually physically very active.On physical examination, he is a tall man with long arms and
legs who appears uncomfortable and diaphoretic; he is lying on the stretcher with his eyes closed. He is
afebrile, with a heart rate of 118 bpm, and blood pressure of 156/64 mm Hg in the right arm and 188/74
mm Hg in the left arm. His head and neck examina-tion is unremarkable. His chest is clear to
auscultation bilaterally, and incidental note is made of pectus excavatum. His heart rate is tachycardic
and regular, with a soft, early diastolic murmur at the right sternal border, and his pulses are bound-ing.
His abdominal examination is benign, and neurologic examination is nonfo-cal. His chest x-ray shows a
widened mediastinum.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 5:

A 58-year-old man presents to the ER complaining of severe pain in his left calf and foot that woke him
from sleep. He has a history of chronic stable angina, hypercholesterolemia, and hypertension, for which
he takes aspirin, atenolol, and simvastatin. He has experienced pain in both calves and feet with walking
for several years, and the pain has gradually progressed so that he can now only walk 100 feet before he
has to stop because of pain. He occasionally has experienced mild pain in his feet at night, but the pain
usually gets better when he sits up and hangs his feet off the bed. This time, the pain was more severe
and did not improve, and he now feels like the foot is numb and he cannot move his toes.On physical
examination, he is afebrile, with heart rate 72 bpm and blood pres-sure 125/74 mm Hg. Head and neck
examination are significant for a right carotid bruit. His chest is clear to auscultation; his heart rhythm is
regular with a nondis-placed apical impulse, an S4 gallop, and no murmurs. His abdomen is benign, with
no tenderness or masses. He has bilateral femoral bruits, and palpable femo-ral and popliteal pulses
bilaterally. His pedal pulses are diminished; they are pres-ent on the right but absent on the left. The left
distal leg and foot are pale and cold to touch, with very slow capillary refill.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 6:

A 56-year-old man comes into your clinic as a new patient. Seven years ago at a work-related health
screening, he was diagnosed with hypertension and hyper-cholesterolemia. At that time, he saw a
physician who prescribed a diuretic and encouraged him to lose some weight and to diet and exercise.
Since that time, the patient has not sought medical attention. During the past 2 months, he has been
experiencing occasional headaches, which he attributes to increased stress at work. He denies chest
pain, shortness of breath, dyspnea on exertion, or paroxysmal nocturnal dyspnea. He smokes one pack
of cigarettes per day and has done so since he was 15 years old. He typically drinks two glasses of wine
with din-ner. On examination, the patient is obese, and you calculate his body mass index (BMI) as 30
kg/m2. His blood pressure is 168/98 mm Hg in the right arm and 170/94 mm Hg in the left arm. His
blood pressure did not change with changes in position. His heart rate is 84 bpm. He has no thyromegaly
or lymphadenopathy. Funduscopic examination reveals narrowing of the arteries, arteriovenous nicking,
and flame-shaped hemorrhages with cotton wool exudates. Cardiac examination reveals that his point
of maximal impulse is displaced 2 cm left of the midclavicu-lar line. There is an S4 gallop. No murmurs
are auscultated. Lung and abdomen examinations are normal.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 7:

A 39-year-old man is brought to the ER by ambulance after he was found wander-ing in the street in a
disoriented state. He is confused and agitated, and further history is obtained from his wife. She reports
that for the last several months he has been complaining of intermittent headaches and palpitations,
and he had experienced feelings of lightheadedness and flushed skin when playing basket-ball. Three
weeks ago, he was diagnosed with hypertension and was started on clonidine twice per day. He took the
clonidine for 2 weeks, but because the drug made him feel sedated, he was instructed by his physician 5
days ago to stop the clonidine and to begin metoprolol twice daily. On examination, he is afebrile, with
heart rate 110 bpm, respiratory rate of 26 breaths per minute, oxygen saturation of 98%, and blood
pressure of 215/132 mm Hg, equal in both arms. He is agitated and diaphoretic, and he is looking
around the room but does not appear to rec-ognize his wife. His pupils are dilated but reactive, and he
has papilledema and scattered retinal hemorrhages. He has no thyromegaly. Heart, lung, and abdomi-
nal examinations are normal. His pulses are bounding and equal in his arms and legs. He moves all of his
extremities well, his reflexes are brisk and symmetric, and he is slightly tremulous. A noncontrast
computed tomography (CT) of the head is read as negative for hemorrhage. Laboratory studies include a
normal leukocyte count and a hemoglobin level of 16.5 g/dL. Serum sodium level is 139 mEq/L,
potassium 4.7 mEq/L, chloride 105 mEq/L, HCO3 29 mEq/L, blood urea nitrogen (BUN) 32 mg/dL, and
creatinine 1.3 mg/dL. Urinalysis is normal, and a urine drug screen is negative. Lumbar puncture is
performed, and the cerebrospinal fluid (CSF) has no red or white blood cells, no xanthochromia, and
normal protein and glucose.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 8:

A healthy 52-year-old man presents to the doctor’s office complaining of increas-ing fatigue for the past
4 to 5 months. He exercises every day, but lately he has noticed becoming short of breath while jogging.
He denies orthopnea, paroxysmal nocturnal dyspnea (PND), or swelling in his ankles. The patient reports
occasional joint pain, for which he uses over-the-counter ibuprofen. He denies bowel changes, melena,
or bright red blood per rectum, but he reports vague left-side abdominal pain for a few months off and
on, not related to food intake. The patient denies fever, chills, nausea, or vomiting. He has lost a few
pounds intentionally with diet and exercise.On examination, he weighs 205 lb, and he is afebrile. There
is slight pallor of the conjunctiva, skin, and palms. No lymphadenopathy is noted. Chest is clear to
auscultation bilaterally. Examination of the cardiovascular system reveals a regular rate and rhythm,
with no rub or gallop. There is a systolic ejection murmur. His abdomen is soft, nontender, and without
hepatosplenomegaly. Bowel sounds are present. He has no extremity edema, cyanosis, or clubbing. His
peripheral pulses are palpable and symmetric. Hemoglobin level is 8.2 g/dL.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 9:

A 24-year-old man presents to the emergency room complaining of 24 hours of fevers with shaking
chills. He is currently being treated for acute lymphoblastic leu-kemia (ALL). His most recent
chemotherapy with hyperfractionated CVAD (cyclo-phosphamide, vincristine, doxorubicin, and
dexamethasone) was 7 days ago. He denies any cough or dyspnea, headache, abdominal pain, or
diarrhea. He has had no sick contacts or recent travel. On physical examination, he is febrile to 103°F,
tachycardic with heart rate 122 bpm, blood pressure 118/65 mm Hg, and respira-tory rate 22 breaths
per minute. He is ill appearing; his skin is warm and moist but without any rashes. He has no oral lesions,
his chest is clear to auscultation, his heart rate is tachycardic but regular with a soft systolic murmur at
the left sternal border, and his abdominal examination is benign. The perirectal area is normal, and
digital rectal examination is deferred, but his stool is negative for occult blood. He has a tunneled
vascular catheter at the right internal jugular vein without ery-thema overlying the subcutaneous tract
and no purulent discharge at the catheter exit site. Of note, he reports an onset of shaking chills 30
minutes after the catheter was flushed. Laboratory studies reveal a total white blood cell count of 1100
cells/mm3, with a differential of 10% neutrophils, 16% band forms, 70% lymphocytes, and 4%
monocytes (absolute neutrophil count 286/mm3). Chest radiograph and urinalysis are normal.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 10:

A 25-year-old African American man is admitted to your service with the diagno-sis of a sickle cell pain
episode. He was admitted to the hospital six times last year with the same diagnosis, and he was last
discharged 2 months ago. Again he presented to the emergency room complaining of abdominal and
bilateral lower extremity pain, his usual sites of pain. When you examine him, you note he is febrile to
101°F, with respiratory rate 25 breaths per minute, normal blood pressure, and slight tachycardia of 100
bpm. Lung examination reveals bronchial breath sounds and egophony in the right lung base. His oxygen
saturation on 2 L/min nasal cannula is 92%. Besides the usual abdominal and leg pain, he is now
complaining of chest pain, which is worse on inspiration. Although he is tender on palpation of his
extremities, the remainder of his examination is normal. His laboratory examinations reveal elevated
white blood cell and reticulocyte counts, and a hemoglobin and hematocrit that are slightly lower than
baseline. Sickle and target cells are seen on the peripheral smear.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 11:

A 28-year-old man comes to the emergency room complaining of 6 days of fever with shaking chills.
Over the past 2 days, he has also developed a productive cough with greenish sputum, which
occasionally is blood streaked. He reports no dyspnea, but sometimes experiences chest pain on deep
inspiration. He does not have headache, abdominal pain, urinary symptoms, vomiting, or diarrhea. He
has no significant medical history. He smokes cigarettes and marijuana regularly, drinks several beers
daily, but denies intravenous drug use.On examination, his temperature is 102.5°F, heart rate 109 bpm,
blood pres-sure 128/76 mm Hg, and respiratory rate 23 breaths per minute. He is alert and talkative. He
has no oral lesions, and funduscopic examination reveals no abnormalities. His jugular veins show
prominent V waves, and his heart rhythm is tachycardic but regular with a harsh holosystolic murmur at
the left lower sternal border that increases with inspiration. Chest examination reveals inspira-tory rales
bilaterally. On both of his forearms, he has linear streaks of induration, hyperpigmentation, and some
small nodules overlying the superficial veins, but no erythema, warmth, or tenderness.Laboratory
examination is significant for an elevated white blood cell (WBC) count at 17,500/mm3, with 84%
polymorphonuclear cells, 7% band forms, and 9% lymphocytes, a hemoglobin concentration of 14 g/dL,
hematocrit 42%, and platelet count 189,000/mm3. Liver function tests and urinalysis are normal. Chest
radiograph shows multiple peripheral, ill-defined nodules, some with cavitation.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 12:

A 28-year-old man comes to the emergency room complaining of 6 days of fever with shaking chills.
Over the past 2 days, he has also developed a productive cough with greenish sputum, which
occasionally is blood streaked. He reports no dyspnea, but sometimes experiences chest pain on deep
inspiration. He does not have headache, abdominal pain, urinary symptoms, vomiting, or diarrhea. He
has no significant medical history. He smokes cigarettes and marijuana regularly, drinks several beers
daily, but denies intravenous drug use.On examination, his temperature is 102.5°F, heart rate 109 bpm,
blood pres-sure 128/76 mm Hg, and respiratory rate 23 breaths per minute. He is alert and talkative. He
has no oral lesions, and funduscopic examination reveals no abnormalities. His jugular veins show
prominent V waves, and his heart rhythm is tachycardic but regular with a harsh holosystolic murmur at
the left lower sternal border that increases with inspiration. Chest examination reveals inspira-tory rales
bilaterally. On both of his forearms, he has linear streaks of induration, hyperpigmentation, and some
small nodules overlying the superficial veins, but no erythema, warmth, or tenderness.Laboratory
examination is significant for an elevated white blood cell (WBC) count at 17,500/mm3, with 84%
polymorphonuclear cells, 7% band forms, and 9% lymphocytes, a hemoglobin concentration of 14 g/dL,
hematocrit 42%, and platelet count 189,000/mm3. Liver function tests and urinalysis are normal. Chest
radiograph shows multiple peripheral, ill-defined nodules, some with cavitation.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 13:

A 42-year-old man complains of 2 days of worsening chest pain and dyspnea. Six weeks ago, he was
diagnosed with non-Hodgkin lymphoma with lymphadenopathy of the mediastinum, and he has been
treated with mediastinal radiation therapy. His most recent treatment was 1 week ago. He has no other
medical or surgical history and takes no medications. His chest pain is constant and unrelated to activity.
He becomes short of breath with minimal exertion. He is afebrile, heart rate 115 bpm with a thready
pulse, respiratory rate 22 breaths per minute, and blood pressure 108/86 mm Hg. Systolic blood
pressure drops to 86 mm Hg on inspiration. He appears uncomfortable and is diaphoretic. His jugular
veins are distended to the angle of the jaw, and his chest is clear to auscultation. He is tachycardic, his
heart sounds are faint, and no extra sounds are appreciated. The chest x-ray is shown below.

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.
Case Scenario 14:

1. What is most likely the diagnosis of the patient? Provide a background of the condition, its
pathophysiology and related discussion.
2. What are the possible dependent and collaborative management for this patient?
3. What are your possible nursing interventions for this condition?
4. Formulate 5 priority nursing diagnoses for the patient. Reason out why you chose each.
5. Create a concept map for the identified diagnosis.