ER Case Studies

1. 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

2. ER Case Study The Macstrak Project

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

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

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

6. ER Case Study 08:25 ENC arrives at the hospital and is triaged at level II. 08:30 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 Macstrak Project

7. ER Case Study 08:40 ER MD assesses ENC and finds no contraindications to thrombolytic therapy. The decision is made to treat ENC (weight 62 kg) with TNK. 08:50 35 mg of TNK over 5 seconds is given. ENC also receives UF heparin IV, metoprolol IV and clopidogrel while in the ER. 09:00 The ER MD makes arrangements to have ENC admitted to the CCU. 09:10 The pain is resolving and the ST segments are normalising. The Macstrak Project

8. ER Case Study On 3/3/06 10:15 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. The Macstrak Project

9. MACSTRAK ER ER Case Study Patient Initials: F M L Birth Date:19 Day Month Year Gender: Male Female Centre: Date:20 Day Month Year E N C 27 04 56 X ENC is a 49 year old (27/4/56) working mom with no significant past medical history. The Macstrak Project

10. MACSTRAK ER ER Case Study Patient Initials: F M L Birth Date:19 Day Month Year Gender: Male Female Centre: Date:02 0220 06 Day Month Year E N C 27 04 56 X ENC is a 49 year old (27/4/56) working mom with no significant past medical history. On 2/3/06: 05:00 ENC is woken up by chest pain. The Macstrak Project

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

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

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

14. 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. 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 X X X The Macstrak Project

15. 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 The Macstrak Project

16. ER Case Study 05:00 ENC is woken up by chest pain. 07:50EMS arrives at ENC’s home 08:25 ENC 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. 08:40 ER MD assesses ENC and finds she has no contraindications to thrombolytic therapy. 05:00 07:50 08:25 08:25 08:30 08:40 The Macstrak Project

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

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

19. 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 The Macstrak Project

20. 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 The Macstrak Project

21. 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 35 1 X The Macstrak Project

22. ER Case Study 08:50 35 mg of TNK over 5 seconds is given. ENC also receives UF heparin IV, metoprolol IV and clopidogrel while in the ER. 08:50 The Macstrak Project

23. 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 The Macstrak Project

24. 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 The Macstrak Project

25. ER Case Study On 3/3/06 10:15 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. 10:15 X The Macstrak Project