The Macstrak Project Ward Case Studies The following is a series of case studies to review different patient types and how they are captured on the form. The information is provided in sequence to reflect the natural progression of a patient’s care. As the case is presented, mark off the required information in the appropriate fields on your Macstrak form. At the end of each case study, the form will be reviewed with the correct answers supplied. If you have any questions, please refer to your Macstrak manual or contact us at the Macstrak Project Office.

The Macstrak Project Ward Case Study

The Macstrak Project Ward Case Study DG is an 82-year-old (02/3/24) retiree with a past medical history of an anterior MI in 1990, and admission for mild CHF in 1992 and hypertension. He is on metropolol and ASA.

The Macstrak Project Ward Case Study DG is an 82-year-old (02/3/24) retiree with a past medical history of an anterior MI in 1990, and admission for mild CHF in 1992 and hypertension. He is on metropolol and ASA. DG awoke on the morning of 10/03/06 with mild shortness of breath and chest congestion. As the day wore on his shortness of breath and chest congestion worsened and he presented to the ER of his local hospital in the late afternoon.

The Macstrak Project Ward Case Study In the ER, on examination, he is found to be moderately dyspneic with crackles bilaterally throughout his lung fields, BP 166/68, and HR 96. He denies having any chest pain. While in the ER he receives furosemide IV and O2 at 40 % via mask. A CXR shows moderate cardiomegaly and interstitial pulmonary edema.

The Macstrak Project Ward Case Study He is admitted to the ward with an admitting diagnosis of CHF. Shortly after admission DG states that his shortness of breath is much improved. On day 1, his O2 is discontinued, his metoprolol dose is reduced and he starts on an ACE Inhibitor. He continues on these medications as well as ASA and furosemide while he is on the ward. He has an echocardiogram on day 3 which shows anterior akinesis but no valvular adnormalities. DG is discharged home on 14/3/06 on ASA po, metropolol po, furosemide and an ACE Inhibitor. His final diagnosis is CHF.

The Macstrak Project Centre: Date: 20 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female Ward Case Study DG is an 82-year-old (02/3/24) retiree with a past medical history of an anterior MI in 1990, and admission for mild CHF in 1992 and hypertension. He is on metropolol and ASA. D G Ward MACSTRAK X A B C D

The Macstrak Project Centre: Date: 20 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female Ward Case Study DG awoke on the morning of 10/03/06 with mild shortness of breath and chest congestion. As the day wore on his shortness of breath and chest congestion worsened and he presented to the ER of his local hospital in the late afternoon. D G Ward MACSTRAK X A B C D

The Macstrak Project Past Medical History : 30 days MI ……………………………. Angina ……………………….. CABG ……………………….. PCI …………………………… CHF ………………………….. TIA/CVA …………………….. Diabetes (oral agents/insulin)... None of the Above……………. Ward Case Study DG is an 82-year-old (02/3/24) retiree with a past medical history of an anterior MI in 1990, and admission for mild CHF in 1992 and hypertension. He is on metropolol and ASA. X X

The Macstrak Project Patient Origin: ER Dr.’s Office/Clinic (Direct) Other Acute Care Hospital Home Direct (Elective) Inpatient CCU Other ICU Other Ward Other: ……………… Ward Case Study In the ER, on examination, he is found to be moderately dyspneic with crackles bilaterally throughout his lung fields, BP 166/68, and HR 96. He denies having any chest pain. While in the ER he receives furosemide IV and O2 at 40 % via mask. A CXR shows moderate cardiomegaly and interstitial pulmonary edema. He is admitted to the ward with an admitting diagnosis of CHF. X

The Macstrak Project Ward Case Study He is admitted to the ward with an admitting diagnosis of CHF. Admitting Diagnosis: (Check one only) Acute AMI UA R/O MI UA RSCP NYD CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………....… Elective: ………………… ACS X

The Macstrak Project Ward Case Study He is admitted to the ward with an admitting diagnosis of CHF. X

The Macstrak Project Ward Case Study DG is an 82-year-old (02/3/24) retiree with a past medical history of an anterior MI in 1990, and admission for mild CHF in 1992 and hypertension. He is on metropolol and ASA. x x TC

The Macstrak Project Ward Case Study In the ER, on examination, he is found to be moderately dyspneic with crackles bilaterally throughout his lung fields, BP 166/68, and HR 96. He denies having any chest pain. While in the ER he receives furosemide IV and O2 at 40 % via mask. A CXR shows moderate cardiomegaly and interstitial pulmonary edema. x x TC x

The Macstrak Project Ward Case Study Shortly after admission DG states that his shortness of breath is much improved. On day 1, his O2 is discontinued, his metoprolol dose is reduced and he starts on an ACE Inhibitor. He continues on these medications as well as ASA and furosemide while he is on the ward. He has an echocardiogram on day 3 which shows anterior akinesis but no valvular adnormalities. x x TC x x x x x KD

The Macstrak Project Ward Case Study Shortly after admission DG states that his shortness of breath is much improved. On day 1, his O2 is discontinued, his metoprolol dose is reduced and he starts on an ACE Inhibitor. He continues on these medications as well as ASA and furosemide while he is on the ward. He has an echocardiogram on day 3 which shows anterior akinesis but no valvular adnormalities. DG is discharged home on 14/3/06 on ASA po, metropolol po, furosemide and an ACE Inhibitor. x x TC x x x x x KD x x x x

The Macstrak Project Ward Case Study Shortly after admission DG states that his shortness of breath is much improved. On day 1, his O2 is discontinued, his metoprolol dose is reduced and he starts on an ACE Inhibitor. He continues on these medications as well as ASA and furosemide while he is on the ward. He has an echocardiogram on day 3 which shows anterior akinesis but no valvular adnormalities. x TC

The Macstrak Project Discharge Diagnosis: Acute MI Unstable Angina Chest Pain NYD CHF Arrhythmia Aortic Dissection Pericardial Disease Other Cardiac Problem: ………… Non Cardiac Problem: …..… ………. Elective: ………… Date: 20 Ward Case Study DG is discharged home on 14/3/06 on ASA po, metropolol po, furosemide and an ACE Inhibitor. His final diagnosis is CHF. Day Month Year Peak CK: Trop: X

The Macstrak Project Ward Case Study DG is discharged home on 14/3/06 on ASA po, metropolol po, furosemide and an ACE Inhibitor. His final diagnosis is CHF. X