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 AB is a 52-year-old businessman (17/5/53) with no significant past medical history. The Macstrak Project Ward Case Study AB is a 52-year-old businessman (17/5/53) with no significant past medical history. On the morning of 20/03/06 he had an episode of pain lasting two and a half hours. He was admitted to the hospital with an Acute Inferior MI and treated with TNK in the ER. He had a positive troponin level in the ER. AB was transferred to the CCU where he had one episode of VT within the first six hours of his MI which reverted to NSR spontaneously. Otherwise he experience no complications post MI. The Macstrak Project Ward Case Study Over his course in hospital he received the following medications: At home In ER In CCU No meds ASA po Metoprolol IV Nitro S/L Heparin IV (UFH) ASA po Metoprolol IV Nitro IV Heparin IV (UFH) The Macstrak Project Ward Case Study AB is admitted to the ward from the CCU on 22/3/06 with a diagnosis of Acute Myocardial Infarction. An ECG is done on arrival to the ward showing T depressison II, III, a VF (15 lead not done) and he is placed on telemetry for 24 hours. While on the ward he receives the following medications: ASA, metorpolol, atorvastatin, and ramipril. He has a stress test on day 4. The Macstrak Project Ward Case Study He has an uneventful stay on the ward and is discharged home on 26/3/06 with a final diagnosis of Inferior MI (peak CK 1041 and peak troponin 21). Discharge medications included ASA, metoprolol, atorvastatin and ramipril. The Macstrak Project Ward Case Study MACSTRAK Patient Initials: A F Birth Date: Ward Gender: B M 17 05 Day Month X Male A Centre: B C D L 19 53 Year Date: 20 Day Month Year Female AB is a 52-year-old businessman (17/5/53) with no significant past medical history. The Macstrak Project Ward Case Study MACSTRAK Patient Initials: A F Birth Date: Ward Gender: B M 17 05 Day Month X Male A Centre: B C D L 19 53 Year Date: 22 03 Day Month 20 06 Year Female AB is admitted to the ward from the CCU on 22/3/06 with a diagnosis of Acute Myocardial Infarction. An ECG is done on arrival to the ward showing T depressison II, III, a VF (15 lead not done) and he is placed on telemetry for 24 hours. 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 AB is a 52-year-old businessman (17/5/53) with no significant past medical history. X The Macstrak Project Ward Case Study Patient Origin: ER Dr.’s Office/Clinic (Direct) Other Acute Care Hospital Home Direct (Elective) X Inpatient X CCU Other ICU Other Ward Other: ……………… AB is admitted to the ward from the CCU on 22/3/06 with a diagnosis of Acute Myocardial Infarction. The Macstrak Project Ward Case Study Admitting Diagnosis: (Check one only) X Acute AMI UA R/O MI ACS UA RSCP NYD CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………....… Elective: ………………… AB is admitted to the ward from the CCU on 22/3/06 with a diagnosis of Acute Myocardial Infarction. The Macstrak Project Ward Case Study ACS: No Chest Pain: X Yes (Probable ischemia only) Prior to Ward 0-6 hrs ……… Prior to Ward 6-24 hrs ….. Prior to Ward 1-7 days ….. If Yes Episodes Yes No X Prolonged* Troponin Yes No NotDone Pos Neg X X X * (> 15 min) X On the morning of 20/03/06 he had an episode of pain lasting two and a half hours. He was admitted to the hospital with an Acute Inferior MI and treated with TNK with in the ER. He had a positive troponin level in the ER. AB was transferred to the CCU where he had one episode of VT within the first six hours of his MI which reverted to NSR spontaneously. Otherwise he experience no complications post MI. The Macstrak Project Ward Case Study Ward Admit ECG: No ACS ST-T LBBB Paced X Other ST ST V1-4 V5-6 I/aVL ………………….. II/III/aVF ………… T Q ……………………………………….. ….. ……. ……. ……………………………………….. ….. ……. ……. ….. ……. ……. ….. ……. X ……. AB is admitted to the ward from the CCU on 22/3/06 with a diagnosis of Acute Myocardial Infarction. An ECG is done on arrival to the ward showing T depressison II, III, a VF (15 lead not done) and he is placed on telemetry for 24 hours. The Macstrak Project Ward Case Study Drugs: PTA ASA ……………………………………………………. Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… PTW Ward Disch 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…………………………... Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. In ER: ASA po Metoprolol IV Nitro S/L Heparin IV (UFH) In CCU: ASA po Metoprolol IV Nitro IV Heparin IV (UFH) x x ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above ………………….. x RN Initials …………………………………….. TC Over his course in hospital he received the following medications: At home: No meds TC The Macstrak Project Ward Case Study Drugs: PTA ASA ……………………………………………………. Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… PTW Ward Disch 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…………………………... Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. x x While on the ward he receives the following medications: ASA, metorpolol, atorvastatin and ramipril. He has a stress test on day 4. x x x x ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above ………………….. x RN Initials …………………………………….. TC TC KD The Macstrak Project Ward Case Study Drugs: PTA ASA ……………………………………………………. Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… PTW Ward Disch 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…………………………... Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. x x While on the ward he receives the following medications: ASA, metorpolol, atorvastatin and ramipril. He has a stress test on day 4. x x x x ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above ………………….. x RN Initials …………………………………….. TC TC KD The Macstrak Project Ward Case Study Drugs: PTA ASA ……………………………………………………. Coumadin ………………………………………. Heparin UFH……………………………. Heparin LMWH………………………… Clopidogrel (or ticlopidine) ……..……. GP 2b/3a Inhibitor (IV)…………… Other Antithrombin …….…………… PTW Ward Disch x Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. HRT ……………………………………………………. 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…………………………... Blocker - Carvedilol …………... x x x ……………………………..….. ……………………………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above ………………….. x RN Initials …………………………………….. TC TC While on the ward he receives the following medications: ASA, metorpolol, atorvastatin and ramipril. He has a stress test on day 4. He has an uneventful stay on the ward and is discharged home on 26/3/06 with a final diagnosis of Inferior MI (peak CK 1041 and peak troponin 21). Discharge medications included ASA, metoprolol, atorvastatin and ramipril. KD TC The Macstrak Project Ward Case Study Events: Ward Telemetry …………………………………………… x 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 . x Echocardiogram …………………………… RNA for LVEF ………........................……. LVEF < 40% (nuc/echo)…………. Other Cardiac Imaging ……………. Non Cardiac Imaging ………………. Research (randomised) ......……………….. Crs5: ……………………………….. Crs6: ……………………………….. Crs7: ……………………………….. Crs8: ……………………………….. None of the Above ……………………... AB is admitted to the ward from the CCU on 22/3/06 with a diagnosis of Acute Myocardial Infarction. An ECG is done on arrival to the ward showing T depressison II, III, a VF (15 lead not done) and he is placed on telemetry for 24 hours. While on the ward he receives the following medications: ASA, metorpolol, atorvastatin, and ramipril. He has a stress test on day 4. RN Initials ………………………………………... TC The Macstrak Project Ward Case Study 03 Date: 26 Day Month 06 20 Year Discharge Diagnosis: X Acute MI Peak CK: 1041 Unstable Angina Trop: 21 Chest Pain NYD CHF Arrhythmia Aortic Dissection Pericardial Disease Other Cardiac Problem: ………….................. Non Cardiac Problem: …..….............………. Elective: ………….......................................... He has an uneventful stay on the ward and is discharged home on 26/3/06 with a final diagnosis of Inferior MI (peak CK 1041 and peak troponin 21). Discharge medications included ASA, metoprolol, atorvastatin and ramipril. 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……………………………. He has an uneventful stay on the ward and is discharged home on 26/3/06 with a final diagnosis of Inferior MI (peak CK 1041 and peak troponin 21). Discharge medications included ASA, metoprolol, atorvastatin and ramipril. 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