Rush University College of Nursing
NSG 510 Pathophysiology
This assignment is worth 5% of the course grade.
1. Assemble a group of eight students.
2. Read through the entire case before answering any questions.
3. Work together to analyze the case, answer the questions with precision, and develop a story board.
We have found that groups that simply divide the content among themselves don’t do as well as
groups that work through the case together.
4. Submit:
a. single copy of the completed case;
b. single copy of the story board (see objectives 1, 2, and 3).
Objectives:
1. identify medical conditions and their supporting data;
2. assert cause-and-effect relationships among medical conditions;
3. incorporate anatomical, physio- and pathophysiologic principles as they apply to 1. and 2.
Suggested approach: Work as a group rather than divide up and assign parts.
1. Individual responsibility: Each individual should read through the case and highlight/answer
important information (active learning);
2. Group responsibility: Discuss the case, exchange ideas, refine answers, develop story board.
Grading rubric:
Case study: Completed
accurately (answers all yellow
highlighted areas)
Conditions: Accurately identified
using specific terminology: For
example, “primary HTN stage 2”,
rather than “hypertension”
Supporting data: Comprehensive
and specific to the condition
Cause-and-effect:
Shows the relationship among
conditions;
Provides pathophysiologic
rationale for the relationship
Accurate,
Comprehensive,
Analytical
1
Correct,
General,
Knowledgeable
.8
Inaccurate,
Vague,
Error prone
.6
Not done
1
.8
.6
0
1
.8
.6
0
1
.8
.6
0
0
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Unfolding Case Study: Part One
Pathophysiologic principles:
 Blood pressure
 Cholesterol
 Bone marrow
Case Presentation
Reason for the encounter: The patient is a 52-year-old peri-menopausal cisgender woman who is at a
primary care clinic for a routine annual exam.
Vital signs:
 98.6-86-16-168/94 (RA) -99% (current visit); BMI: 32
 97.6-80-20-150/92 (RA) – 99% (one year ago); BMI: 30
 98.4-76-18-156/82 (RA) – 99% (two years ago); BMI: 28
Interpret these vital signs.
What condition(s) does this patient have based on the vital signs?
History:
 Medical: Irregular menses, menorrhagia
 Surgical: NA
 Social: Lives with spouse, two teenage children; does not smoke, drinks occasionally.
 Family: Mother deceased, cause of death (COD) stroke; father deceased, COD heart attack; sister
alive, renal insufficiency.
Labs: Highlight values that are outside the range of normal (red highlight for elevated; blue highlight for
low) and interpret the results.
BMP
CBC
Na
142 mOsm/L
WBC
9.8
K
3.9 mOsm/L
RBC
2.9
Cl
105
Hemoglobin
9
CO2
24
Hematocrit
27
BUN
10
MCV
68
Creatinine
0.5
MCHC
25
eGFR
90 mLs/minute
Platelet
220
Fasting blood sugar (FBS) 95
Think about the labs both individually (normal or abnormal) and conceptually. Here are the big
concepts: Electrolytes, kidney function, bone marrow (white blood cells, red blood cells (and indices)
and platelets). What medical condition is suggested by the history and laboratory data?
Allergies: No known allergies
Med List:
Drug: Generic (Trade)
Dose
Route
Mechanism
2
Acetaminophen
(Tylenol)
Ibuprofen (Motrin)
500 – 1000 mg q
8 hrs prn
200-600 mg q 8
hrs prn
Oral
Analgesic
Oral
Non-steroidal anti-inflammatory
Physical exam: Highlight findings on the physical exam that are not normal.
 Constitutional: Appears well.
 HEENT: Normocephalic; PERRLA, conjunctiva pale, red reflex and vessels visible; canals clear, drums
pearly gray; mucus membranes moist, teeth in good repair; neck supple, thyroid not palpable.
 Cardiac: Skin warm, distal pulses 2+, no edema; S1, S2, + S4, no murmur/rub.
 Respiratory: Chest symmetrical, vesicular sounds in periphery, no crackles or wheezes.
 Abd: No scars; BS + in four quadrants; percussive note tympanic; no masses.
 GU: Deferred.
 Extremities: Feet warm, no lesions, dorsalis pedis and posterior tibial 2+, no neuropathy.
The results of the LIPID PANEL blood test are listed below.
Highlight values that are outside the range of normal (red highlight for elevated; blue highlight for low).
LIPID PANEL
Cholesterol total
265 mg/dL
Triglyceride
100 mg/dL
HDL cholesterol
26 mg/dL
LDL cholesterol
170 mg/dL
What arterial condition is suggested by the history and LIPID PANEL?
The patient leaves the appointment with the following prescriptions. Do not worry about the dose and
route of the medicine. Look at the names and the mechanisms of action.
Drug: Generic (Trade)
Atorvastatin
Ferrous sulfate
Hydrochlorothiazide
Nifedipine SR
Dose
20 mg daily
324 mg daily
25 mg daily
30 mg daily
Route
oral
oral
oral
oral
Mechanism of action
Removes bad cholesterol from the blood
Iron replacement
Blocks reabsorption of Na/H20 in nephron
Decreases arterial resistance
Start the story board. There are at least three and possibly four medical conditions from part one.
 Make sure each condition is accurately identified using specific terminology.
 Provide supporting data that is comprehensive and specific to the condition. Consider the following
sources and organization for supporting data: Reason for seeking health care, VS, history, labs and
diagnostic tests, medications, etc.
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Unfolding Case Study: Part Two
Pathophysiologic principles:
 Ischemic heart disease: Stable angina versus acute coronary syndromes
 Myocardial oxygen supply and demand
 Oxygenation
 Renal function
Case Presentation
Reason for the encounter: The patient is now 57 years old and is seen in the Emergency Department for
three hours of persistent indigestion, nausea, diaphoresis and chest discomfort. She is mildly anxious.
Vital signs in 15-minute intervals most recent first.
 98.6-110-16-160/88 (2L) -99% (current visit); BMI: 35
 97.6-100-20-180/86 (2L) – 99%; BMI: 35
 98.4-102-18-156/86 (2L) – 99%; BMI: 35
Focused Physical Exam: Highlight findings on the physical exam that are not normal.
 Constitutional: Distressed, sitting upright, rubbing chest.
 HEENT: Deferred
 Cardiac: Skin cool, distal pulses 1+, no edema, S1, S2, + S4, new murmur left sternal border.
 Respiratory: Chest symmetrical, no wheezes or crackles.
 Abd: Deferred.
 GU: Deferred.
 Extremities: Deferred.
Think about myocardial (heart muscle) oxygen supply and demand.
Think about demand as how
forcefully and frequently the
myocardium (heart muscle)
is contracting. The greater
the force and frequency, the
greater the oxygen demand.
Demand is a function of
systemic artery resistance
(BP), ventricular volume
(preload), and heart rate.
Think about supply as the
delivery of blood through
the coronary arteries
(shown and labelled above).
For adequate supply, the
blood must be oxygenated
(PaO2, SaO2, and
hemoglobin normal) and
the artery must be patent
(i.e., have no blockage).
Sort this word list highlighting that indicate decreased supply in blue and words that indicate increased
demand in red. Not all words are used!
HR 160
SaO2 75%
PaO2 50 mmHg
Increased blood
volume
Coronary artery
occlusion: 50%
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SaO2 95%
BP 120/60
Stenotic aortic
valve
PaO2 85 mmHg
HDL cholesterol
90 mg/dL
Hemoglobin 15
g/dL
LDL Cholesterol
200 mg/dL
Coronary artery
patent
Decreased blood
volume
HR 70
Hemoglobin 7
g/dL
PaCO2 60 mmHg
Increased physical
exercise
PaCO2 40 mmHg
BP 160/80
When there is either decreased supply, increased demand, or most commonly a combination of the two,
a patient is at risk for ischemia and, if unrelieved, myocardial injury, infarction, and necrosis.
This patient has a risk for decreased supply based on a couple of conditions revealed in Part One. Which
conditions suggest a decreased oxygen supply?
Now, she’s experiencing increased demand based on her vital signs. List of vital signs suggesting an
increased oxygen demand.
History:
 Medical: Write out the conditions identified from Part One.
 Surgical: NA
 Social: Lives with spouse; does not smoke, drinks occasionally.
 Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal
insufficiency.
Labs: Highlight values that are outside the range of normal (red highlight for elevated; blue highlight for
low).
BMP
CBC
Na
140 mOsm/L
WBC
9.0
K
4.0 mOsm/L
RBC
3
Cl
100
Hemoglobin
8.9
CO2
24
Hematocrit
27
BUN
15
MCV
75
Creatinine
1.4
MCHC
28
eGFR
43 mLs/minute
Platelet
220
FBS
100
LIPID PANEL
Thyroid Panel
Cholesterol total
150 mg/dL
TSH
1.2 uIU/mL
Triglyceride
60 mg/dL
HDL cholesterol
30 mg/dL
Diabetic panel
LDL cholesterol
85 mg/dL
HA1C
5.5%
CARDIAC
Average glucose
100
Troponin I
2.3 ng/mL
Diagnostic tests:
ECG: Sinus tachycardia; ST segment elevation I, aVL, V1-V3. Interpretation: Acute changes consistent
with myocardial injury and ischemia anterior and lateral left ventricle.
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Cardiac catheterization: Diffuse non-occlusive atherosclerosis at bifurcations of right and left coronary
arteries. 100% occlusion, presumed thrombosis, of left interventricular coronary artery.
Allergies: No known allergies
Home Med List; hospital meds in italics.
Drug: Generic
Dose
Alteplase (Activase)
NA
Aspirin
81 mg daily
Atorvastatin
20 mg daily
Ferrous sulfate
324 mg daily
Hydrochlorothiazide
25 mg daily
Nifedipine SR
30 mg daily
Route
Intravenous
oral
oral
oral
oral
oral
Mechanism of action
Thrombolysis
Prevents platelets from sticking together
Removes bad cholesterol from the blood
Iron replacement
Blocks reabsorption of Na/H20 in nephron
Decreases arterial resistance
Acute
Coron
ary
Syndr
omes
Here’s a challenging table to help sort out the conditions that cause chest pain. For each of the four
conditions write a sentence. Three sentences should begin with “It can’t be …. because…..” or “It has to
be … because….”
Conditions
Stable angina
Unstable angina
NSTEM
STEMI
Sentence
Acute coronary syndromes always involve coronary artery thrombus causing an acute reduction in
myocardial oxygen supply. If the thrombus is transient, the patient will have reversible ischemia
(unstable angina). If it lasts long enough, the patient will have ischemia that leads to irreversible
necrosis (NSTEMI or STEMI).
Since the thrombus is the immediate threat, its degradation is a clinical priority. To degrade the
thrombus, the patient is treated with alteplase and aspirin (see above).
She spends one week in the hospital and is discharged to home with follow-up cardiac rehabilitation.
On the day of discharge, her vital signs are
Vital signs on discharge: 99.4-72-20-124/72-95% (on room air)
There are two new conditions to add to the story board.
 Make sure each condition is accurately identified using specific terminology.
 Provide supporting data that is comprehensive and specific to the condition. Consider the following
sources and organization for supporting data: Reason for seeking health care, VS, history, labs and
diagnostic tests, medications, etc.
 Add cause and effect arrows between the conditions and explain the relationship with basic
pathophysiological principles.
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Unfolding Case Study: Part Three
Pathophysiologic principles:
 Heart failure
 Renin angiotensin aldosterone system and sympathetic nervous system
 Hemodynamics: Preload, afterload, contractility.
Case Presentation
The patient is now 62 years old. She is experiencing worsening shortness of breath, cannot walk more
than a block without getting fatigued, has gained weight, and her shoes are tight. The provider advises
the patient to go to the Emergency Department (ED). In the ED she sits in a high fowler’s position and is
laboring to breathe.
Vital signs in 15-minute intervals with most recent first; weight in pounds is added



98.6-72-24-148/88-92% (on 2L/minute nasal cannula); 184#
97.6-100-28-144/86 (RA) – 89% (on room air); 184# (Ordered and given furosemide 20 mg IVP)
98.4-102-18-156/86 (RA) – 89% (on room air); 184# (Started on oxygen 2L via nasal cannula).
History:




Medical: Write out the conditions identified from Parts One and Two
Surgical: NA
Social: Lives with spouse; does not smoke, drinks occasionally.
Family: Mother deceased, COD stroke; father deceased, COD heart attack; sister alive, renal
insufficiency.
Meds: No known allergies.
Home medicines (notice, the patient is no longer taking nifedipine and has started on enalapril):
Drug: Generic
Dose
Route
Indication
Aspirin
325 mg daily Oral/AM
Prevents platelets from sticking together
Atorvastatin
80 mg daily
Oral/PM
Removes bad cholesterol from the blood
Carvedilol
25 mg twice Oral/AM
Blocks sympathetic nervous system
a day
Enalapril
20 mg daily
Oral/AM
Blocks renin, angiotensin, aldosterone
Ferrous sulfate
324 mg daily Oral AM
Iron replacement
Hydrochlorothiazide
25 mg daily
Oral
Blocks reabsorption of Na/H20 in nephron
Focused Physical Exam: Highlight findings on the physical exam that are not normal.
 Constitutional: Moderately distressed, sitting upright, legs over side of stretcher.
 HEENT: Deferred
 Cardiac: Skin cool, jugular vein distension, distal pulses 1+, bilateral edema both lower extremities,
S1, S2, + S3, no murmur/rub.
 Respiratory: Chest symmetrical, wet cough, scattered crackles throughout.
 Abd: Deferred.
 GU: Deferred.
 Extremities: Deferred.
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Labs: Highlight values that are outside the range of normal (red highlight for elevated; blue highlight for
low).
BMP
CBC
Na
140 mOsm/L
WBC
9.0
K
4.8 mOsm/L
RBC
4
Cl
100
Hemoglobin
12
CO2
24
Hematocrit
36
BUN
18
MCV
92
Creatinine
1.6
MCHC
34
eGFR
35 mLs/minute
Platelet
220
FBS
100
LIPID PANEL
Thyroid Panel
Cholesterol total
150 mg/dL
TSH
1.2 uIU/mL
Triglyceride
60 mg/dL
HDL cholesterol
30 mg/dL
Diabetic panel
LDL cholesterol
85 mg/dL
HA1C
5.2%
CARDIAC
Average glucose
98
Troponin I
< 0.1 ng/mL
Natriuretic peptide
2000 pg/mL
(BNP) (nl<125; HF > 900)
Diagnostic Tests
CXR: Dilated cardiac silhouette (see XRAY – the heart
width (blue arrow) should be half the thoracic width (black arrow)).
Lung congestion.
Echocardiogram (not shown): Thin ventricular walls, enlarged left
ventricular chamber, and stroke volume (SV) 30 mLs, end diastolic
volume (EDV = preload) = 120 mLs; ejection fraction (EF) 25%
(EF = SV/EDV)
So much information! It’s easy to get confused between acute coronary syndromes (i.e., what’s
happening in part two of the case) and heart failure (what’s happening in part three of the case). Look
at the table below. Sort the data into the correct table cells. This is an example of a compare and
contrast table. Not all cells will be filled.
NSTEMI/STEMI
HF
Symptoms
ST segment changes; Q waves
Elevated troponin
Lab tests
Shortness of breath and
dyspnea
Occlusion or reduced flow
through coronary arteries
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ECG
Xray
Cardiac catheterization
Enlarged heart, congested lungs
Elevated natriuretic peptide
Decreased flow through the
coronary arteries
Chest pain or anginal equivalent
Heart failure is a general term encompassing an annoying variety of subcategories. Complete the
following sentences
“We are confident this patient is experiencing …………. (HFpEF or HFrEF) because of the following clinical
findings ………. (list findings that are specific to either HFpEF or HFrEF).”
“This patient is also showing signs of …………. (left heart failure, right heart failure, or both) because of
the following (if both, identify if the finding suggests left or right failure).”
Here’s an important quote and image from the text about heart failure and compensatory responses.
“When the heart fails to provide adequate cardiac output to meet tissue demands (definition of heart
failure), a number of compensatory mechanisms are triggered”.
Compensatory Mechanisms
“In the short term,
compensatory
mechanisms are
helpful in restoring
cardiac output
toward normal
levels.”
Continued compensatory mechanisms over time are detrimental
causing loss of myocytes (think thinning of the ventricular wall) and
accumulation of fibrotic myocardium (think stiff ventricle unable to
pump – low stroke volume and ejection fraction). These changes
lead to disease progression worsening of heart failure.
Cardiac Output
Let’s start thinking about pharmacology. Why? Because pathophysiology is typically the driver of
pharmacology. Here are the medicines this patient is taking: aspirin, atorvastatin, carvedilol, enalapril,
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ferrous sulfate, and hydrochlorothiazide. Toss in furosemide for good measure. The mechanisms of
action are listed in the medication table. Now look the image immediately above and for each drug the
patient is taking to treat heart failure (not all drugs are used to treat heart failure) write a sentence
formatted as follows:
“The patient is taking …… (name of drug) because the drug stops the detrimental effects of ………. (list
which compensatory response the drug is targeting) on cardiac myocytes.”
There is a new condition to add to the story board.
 Make sure the condition is accurately identified using specific terminology.
 Provide supporting data that is comprehensive and specific to the condition. Consider the following
sources and organization for supporting data: Reason for seeking health care, VS, history, labs and
diagnostic tests, medications, etc.
 Add cause and effect arrows between the conditions and explain the relationship with basic
pathophysiological principles.
Let’s bring this case to a close. The patient is “tuned up” with a variety of medicines, dietary strategies,
and cardiac rehabilitation. Discharge planning includes follow up with primary care.
10
Here’s a sample case of a patient with three conditions: HTN, CKD, Basal cell carcinoma.
HTN: primary
stage 2 HTN.
Cause and effect arrow with
explanation: HTN damages renal
arteries. Increased pressure + failed
autoregulation -> ischemic ->
atrophy -> CKD
CKD: stage 2
CKD.
Key:
 Double circle: Patient
 Single circle: Medical condition
 Square below: Supporting date
 Arrow with square above:
Cause and effect with simple
explanation
See Supporting data under HTN.
Supporting data: Be detailed and
specific here. Include information
that helps confirm the diagnosis.
Don’t speculate and don’t include
non-relevant information or highly
unlikely information.
Consider adding elements of
physiology or pathophysiology if
appropriate.
60-year-old male for
regular exam
Present the supporting data in an
orderly manner of your choice.
Basal cell
carcinoma
See Supporting data under HTN
Here’s what this story tells the reader (me).
The student can
1. identify medical conditions from a patient record.
2. support the medical condition with detailed and specific data.
3. describe pathophysiologically based cause and effect.
4. recognize that some conditions a patient has may not be
relevant to any of the others (Basal cell carcinoma unrelated to
HTN and CKD).
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