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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 on theme: "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."— Presentation transcript:

1 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.

2 The Macstrak Project ER Case Study

3 The Macstrak Project ER Case Study ENC is a 49 year old (27/4/56) working mom with no significant past medical history.

4 The Macstrak Project ER Case Study ENC is a 49 year old (27/4/56) working mom with no significant past medical history. On 2/3/06: 05:00ENC is woken up by chest pain. 07:35The pain persists and ENC’s husband phones for an ambulance.

5 The Macstrak Project ER Case Study 07:50EMS arrives at ENCs home. 08:05An ECG is done enroute to the hospital is as follows: ST in leads II, III, aVF ASA is given.

6 The Macstrak Project ER Case Study 08:25ENC arrives at the hospital and is triaged at level II. 08:30RN assessment reveals her vital signs are as follows BP 130/70, HR 74 and chest is clear. ENC continues to have chest pain which she rates at 8/10.

7 The Macstrak Project ER Case Study 08:40ER MD assesses ENC and finds no contraindications to thrombolytic therapy. The decision is made to treat ENC (weight 62 kg) with TNK. 08:5035 mg of TNK over 5 seconds is given. ENC also receives UF heparin IV, metoprolol IV and clopidogrel while in the ER. 09:00The ER MD makes arrangements to have ENC admitted to the CCU. 09:10 The pain is resolving and the ST segments are normalising.

8 The Macstrak Project ER Case Study On 3/3/06 10:15A CCU bed is not immediately available and ENC is eventually transferred to the CCU, over 24 hours after arriving, with a discharge diagnosis of acute myocardial infarction.

9 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 ENC is a 49 year old (27/4/56) working mom with no significant past medical history. E N C 27 04 56 ER MACSTRAK X

10 The Macstrak Project Centre: Date: 02 02 20 06 Day Month Year Patient Initials: F M L Birth Date: 19 Day Month Year Gender: Male Female ER Case Study ENC is a 49 year old (27/4/56) working mom with no significant past medical history. On 2/3/06: 05:00ENC is woken up by chest pain. E N C 27 04 56 ER MACSTRAK X

11 The Macstrak Project ER Case Study ENC is woken up by chest pain. X

12 The Macstrak Project ER Case Study The pain persists and ENC’s husband phones for an ambulance. X

13 The Macstrak Project ER Case Study ENC arrives at the hospital and is triaged at level II. X

14 The Macstrak Project VS at Presentation: VS Absent Systolic BP: Dyspnea/Rales: < 100 None 101-130 Mild 131-160 Mod/Severe 161-190 >190 Heart Rate: < 60 61-80 81-100 >100 ER Case Study RN assessment reveals her vital signs are as follows BP 130/70, HR 74 and chest is clear. ENC continues to have chest pain which she rates at 8/10. X X X

15 The Macstrak Project ER Case Study RN assessment reveals her vital signs are as follows BP 130/70, HR 74 and chest is clear. ENC continues to have chest pain which she rates at 8/10. X X X X X

16 The Macstrak Project ER Case Study 05:00ENC is woken up by chest pain. 07:50EMS arrives at ENC’s home 08:25ENC arrives at the hospital and is triaged at level II. 08:30RN assessment reveals her vital signs are as follows BP 130/70, HR 74 and chest is clear. ENC continues to have chest pain which she rates at 8/10. 08:40ER MD assesses ENC and finds she has no contraindications to thrombolytic therapy. 05:00 08:25 08:30 08:40 07:50

17 The Macstrak Project ER Case Study An ECG is done en-route to the hospital is as follows: ST in leads II, III, aVF X X

18 The Macstrak Project ER Case Study 08:05An ECG is done en-route to the hospital is as follows: ST in leads II, III, aVF 08:05 X

19 The Macstrak Project ER Case Study RN assessment reveals her vital signs are as follows BP 130/70, HR 74 and chest is clear. ENC continues to have chest pain which she rates at 8/10. The pain is resolving and the ST segments are normalising. X X

20 The Macstrak Project ER Case Study ASA is given. 35 mg of TNK over 5 seconds is given. ENC also receives UF heparin IV, metoprolol IV and clopidogrel while in the ER. X X X X

21 The Macstrak Project ER Case Study 35 mg of TNK over 5 seconds is given. ENC also receives UF heparin IV, metoprolol IV and clopidogrel while in the ER. X X X X 35 1

22 The Macstrak Project ER Case Study 08:5035 mg of TNK over 5 seconds is given. ENC also receives UF heparin IV, metoprolol IV and clopidogrel while in the ER. 08:50

23 The Macstrak Project ER Case Study A CCU bed is not immediately available and ENC is eventually transferred to the CCU, over 24 hours after arriving, with a discharge diagnosis of acute myocardial infarction. X

24 The Macstrak Project ER Case Study A CCU bed is not immediately available and ENC is eventually transferred to the CCU, over 24 hours after arriving, with a discharge diagnosis of acute myocardial infarction. X

25 The Macstrak Project ER Case Study On 3/3/06 10:15A CCU bed is not immediately available and ENC is eventually transferred to the CCU, over 24 hours after arriving, with a discharge diagnosis of acute myocardial infarction. X 10:15

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