The Macstrak Project ER Case Studies The following is a series of case studies to review different patient types and how they are captured on the form.

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Presentation transcript:

The Macstrak Project ER 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 ER Case Study

The Macstrak Project ER Case Study AB is a 48 year old (17/5/57) businessman.

The Macstrak Project ER Case Study AB is a 48 year old (17/5/57) businessman. On 2/2/06: 06:30AB awakens with crushing retrosternal chest pain radiating to his left arm.

The Macstrak Project ER Case Study 08:30AB’s wife drives him to the ER as he continues to have chest pain. He is triaged as a level II and placed in the cardiac room. 08:35Nursing assessment reveals persistent, crushing midsternal chest pain lasting 2 hours. AB has no previous cardiac history. On examination, his BP is 140/70, HR is 72 and his chest is clear. He remains in mild distress with persistent chest pain.

The Macstrak Project ER Case Study 08:37An IV is started and morphine is given. His first and diagnostic ECG is as follows: ST in leads II, III, a VF ST in leads V 1-4 and I, aVL 15 lead ECG:V 4 R shows ST V 7-9 shows ST Nitro 0.3 mg S/L and ASA are given.

The Macstrak Project ER Case Study 08:45AB is assessed by the ER MD and thrombolysis is ordered. 08:55Heparin IV (LMW) is started. Cardiac bloodwork is drawn including troponin and CK levels. 09:0040 mg TNK over 5 seconds. 09:10IV metoprolol is given. The ER MD makes arrangements to have AB admitted to the CCU.

The Macstrak Project ER Case Study 10:30Chest pain gradually subsiding. A repeat ECG shows the ST segments resolving. Troponin level is positive and CK is :15Transferred to CCU, in stable condition, diagnosed with having experienced and acute inferior MI.

The Macstrak Project Centre: Date: 20 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female ER Case Study AB is a 48 year old (17/5/57) businessman. A B ER MACSTRAK X

The Macstrak Project Centre: Date: Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female ER Case Study AB is a 48 year old (17/5/57) businessman. On 2/2/06: AB awakens with crushing retrosternal chest pain radiating to his left arm. A B ER MACSTRAK X

The Macstrak Project ER Case Study AB’s wife drives him to the ER as he continues to have chest pain. He is triaged as a level II and placed in the cardiac room. X

The Macstrak Project ER Case Study AB’s wife drives him to the ER as he continues to have chest pain. He is triaged as a level II and placed in the cardiac room. X

The Macstrak Project ER Case Study AB’s wife drives him to the ER as he continues to have chest pain. He is triaged as a level II and placed in the cardiac room. X

The Macstrak Project VS at Presentation: VS Absent Systolic BP: Dyspnea/Rales: < 100 None Mild Mod/Severe >190 Heart Rate: < >100 ER Case Study Nursing assessment reveals persistent, crushing midsternal chest pain lasting 2 hours. AB has no previous cardiac history. On examination, his BP is 140/70, HR is 72 and his chest is clear. He remains in mild distress with persistent chest pain. X X X

The Macstrak Project ER Case Study Nursing assessment reveals persistent, crushing midsternal chest pain lasting 2 hours. AB has no previous cardiac history. On examination, his BP is 140/70, HR is 72 and his chest is clear. He remains in mild distress with persistent chest pain. X X X X X

The Macstrak Project ER Case Study 06:30AB awakens with crushing retrosternal chest pain radiating to his left arm. 08:30ABs wife drives him to the ER as he continues to have chest pain. He is triaged as a level II and placed in the Cardiac Room. 08:35Nursing assessment reveals persistent, crushing midsternal chest pain lasting 2 hours. 08:45AB is assessed by the ER MD and thrombolysis is ordered. 06:30 08:30 08:35 08:45

The Macstrak Project ER Case Study His first and diagnostic ECG is as follows: ST in leads II, III, a VF ST in leads V 1-4 and I, aVL 15 lead ECG: V 4 R shows ST V 7-9 shows ST X X X X X X X X

The Macstrak Project ER Case Study 08:37His first and diagnostic ECG is as follows: ST in leads II, III, a VF ST in leads V 1-4 and I, aVL 15 lead ECG: V 4 R shows ST V 7-9 shows ST 08:37

The Macstrak Project ER Case Study Nursing assessment reveals persistent, crushing midsternal chest pain lasting 2 hours. Chest pain gradually subsiding. A repeat ECG shows the ST segments resolving. Troponin level is positive and CK is 403. X X X X

The Macstrak Project ER Case Study Nitro 0.3 mg S/L and ASA are given. Heparin IV (LMW) is started. Cardiac bloodwork is drawn including troponin and CK levels. IV metoprolol is given. The ER MD makes arrangements to have AB admitted to the CCU. X X X X

The Macstrak Project ER Case Study AB is assessed by the ER MD and thrombolysis is ordered. 40 mg TNK over 5 seconds. X X X X 40 1

The Macstrak Project ER Case Study 09:0040 mg TNK over 5 seconds. 09:00

The Macstrak Project ER Case Study Transferred to CCU, in stable condition, diagnosed with having experienced and acute inferior MI. X

The Macstrak Project ER Case Study Transferred to CCU, in stable condition, diagnosed with having experienced and acute inferior MI. X

The Macstrak Project ER Case Study 11:15Transferred to CCU, in stable condition, diagnosed with having experienced and acute inferior MI. X 11:15