Transcript Document
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 Ward Case Study MACSTRAK Patient Initials: D F Birth Date: Ward Gender: G M 02 03 Day Month X Male A Centre: B C D L 19 24 Year Date: 20 Day Month Year Female 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 MACSTRAK Patient Initials: D F Birth Date: Ward Gender: G M 02 03 Day Month X Male A Centre: B C D L 19 24 Year Date: 10 03 Day Month 20 06 Year Female 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 Past Medical History: <30 days MI ……………………………. Angina ……………………….. CABG ……………………….. PCI …………………………… CHF ………………………….. TIA/CVA …………………….. Diabetes (oral agents/insulin) ... None of the Above……………. >30 days X X 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 Patient Origin: X ER Dr.’s Office/Clinic (Direct) Other Acute Care Hospital Home Direct (Elective) Inpatient CCU Other ICU Other Ward Other: ……………… 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. The Macstrak Project Ward Case Study Admitting Diagnosis: (Check one only) Acute AMI UA R/O MI ACS UA RSCP NYD X CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………....… Elective: ………………… He is admitted to the ward with an admitting diagnosis of CHF. The Macstrak Project Ward Case Study ACS: X No Chest Pain: Yes (Probable ischemia only) If Yes Episodes Yes No Prolonged* Troponin Yes No NotDone Pos Neg Prior to Ward 0-6 hrs ……… Prior to Ward 6-24 hrs ….. Prior to Ward 1-7 days ….. He is admitted to the ward with an admitting diagnosis of CHF. * (> 15 min) The Macstrak Project Ward Case Study Drugs: PTA PTW Ward Disch ASA ……………………………………………………. x Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… Oral Hypoglycemic ………………… Insulin ………………………………………………. Statin …………………………………………………. Other Antilipid …………………………... Bronchodilator …………………………… Digoxin ……………………………………………. Any Antiarrhythmic ………………. Calcium Antag …………………………… ACEI .…………………………………………………… A2 blocker ………………………………………. Other Vasodilator ……...………………. Diuretic ……………………….……………………... Nitrates top/oral ………………………….. Nitrates IV ……………………………….……... Blocker - Any…………………………... x Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. 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. ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above ………………….. RN Initials …………………………………….. TC The Macstrak Project Ward Case Study Drugs: PTA PTW Ward Disch ASA ……………………………………………………. x Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… Oral Hypoglycemic ………………… Insulin ………………………………………………. Statin …………………………………………………. Other Antilipid …………………………... Bronchodilator …………………………… Digoxin ……………………………………………. Any Antiarrhythmic ………………. Calcium Antag …………………………… ACEI .…………………………………………………… A2 blocker ………………………………………. Other Vasodilator ……...………………. Diuretic ……………………….……………………... Nitrates top/oral ………………………….. Nitrates IV ……………………………….……... Blocker - Any…………………………... x Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. x 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. ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above ………………….. RN Initials …………………………………….. TC TC The Macstrak Project Ward Case Study Drugs: PTA PTW Ward Disch ASA ……………………………………………………. x Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… x Oral Hypoglycemic ………………… Insulin ………………………………………………. Statin …………………………………………………. Other Antilipid …………………………... Bronchodilator …………………………… Digoxin ……………………………………………. Any Antiarrhythmic ………………. Calcium Antag …………………………… ACEI .…………………………………………………… A2 blocker ………………………………………. Other Vasodilator ……...………………. Diuretic ……………………….……………………... Nitrates top/oral ………………………….. Nitrates IV ……………………………….……... Blocker - Any…………………………... x Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. x x x x ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. 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. None of the Above ………………….. RN Initials …………………………………….. TC TC KD The Macstrak Project Ward Case Study Drugs: PTA PTW Ward Disch ASA ……………………………………………………. x Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… x x x x x x x x Oral Hypoglycemic ………………… Insulin ………………………………………………. Statin …………………………………………………. Other Antilipid …………………………... Bronchodilator …………………………… Digoxin ……………………………………………. Any Antiarrhythmic ………………. Calcium Antag …………………………… ACEI .…………………………………………………… A2 blocker ………………………………………. Other Vasodilator ……...………………. Diuretic ……………………….……………………... Nitrates top/oral ………………………….. Nitrates IV ……………………………….……... Blocker - Any…………………………... x Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. x ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above ………………….. RN Initials …………………………………….. TC 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. TC KD KD DG is discharged home on 14/3/06 on ASA po, metropolol po, furosemide and an ACE Inhibitor. The Macstrak Project Ward Case Study Events: Ward Telemetry …………………………………………… RSCP - ischemia - definite ….. - probable .. Code ………………………………………………………. Sustained SVT (no code) ………… Sustained VT (no code) ……………. (1) CVA* ………………………………………………. (2) Major Bleed* …………………………….. Transfusion ………………………………………. Coronary Angiography …………. PCI ………..…………………………………………………. Exercise Test …………………………………... Exercise Test with image ………. Drug Stress Test with image . Echocardiogram …………………………… x RNA for LVEF ………........................……. LVEF < 40% (nuc/echo)…………. Other Cardiac Imaging ……………. Non Cardiac Imaging ………………. Research (randomised) ......……………….. 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. Crs5: ……………………………….. Crs6: ……………………………….. Crs7: ……………………………….. Crs8: ……………………………….. None of the Above ……………………... RN Initials ………………………………………... TC The Macstrak Project Ward Case Study 03 Date: 26 Day Month 06 20 Year Discharge Diagnosis: Acute MI Peak CK: Unstable Angina Trop: Chest Pain NYD X CHF Arrhythmia Aortic Dissection Pericardial Disease Other Cardiac Problem: ………….................. Non Cardiac Problem: …..….............………. Elective: ………….......................................... 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 Ward Case Study Discharge To: (Check one only) X Home CCU Other ICU OR for CV Surgery OR for Other Surgery Death Medical ward Surgical Ward Rehab/Chronic Care Hosp Other Acute Care Hosp Other……………………………. 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