the macstrak project er case studies the following is a series of case studies to review different...
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
DRB is a 76 year old male (13/02/30) who had a large anterior infarction 3 years ago.
The Macstrak Project
ER Case Study
DRB is a 76 year old male (13/02/30) who had a large anterior infarction 3 years ago.
On 15/3/06:
17:30DRM experiences a new onset of shortness of breath (SOB) with minimal exertion while at home. The dyspnea was increasing and he decides to present to the ER.
The Macstrak Project
ER Case Study
18:30Arrives in the ER (non EMS) with persistent SOB.
18:40Triaged level III.
18:45Nursing assessment reveals that DRB has gained 3 kg with peripheral edema over the past week and has had increasing dyspnea on exertion. Tonight, his dyspnea worsened and progressed to dyspnea at rest. He denies chest pain. On examination, his BP is 140/90 and his HR is 110. On ausculation, he has mod/severe rales bilaterally.
The Macstrak Project
ER Case Study
18:55ECG shows Left Bundle Branch Block (LBBB).
19:00Seen by the ER MD who orders diuretics IV, NTG S/L, routine bloodwork and a chest X-ray.
19:15Chest X-ray confirms pulmonary edema.
20:15DRB’s dyspnea improves following diuresis.
The Macstrak Project
ER Case Study
20:20ER MD decides DRB should be admitted to the ward.
22:00Admitted to the ward service in stable condition with CHF.
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
DRB is a 76 year old male (13/02/30) who had a large anterior infarction 3 years ago.
D R B
13 02 30
ER
MACSTRAK
X
The Macstrak Project
Centre:
Date: 15 03 20 06 Day Month Year
Patient Initials: F M L
Birth Date: 19
Day Month Year
Gender: Male Female
ER Case Study
DRB is a 76 year old male (13/02/30) who had a large anterior infarction 3 years ago.
On 15/3/06:
DRM experiences a new onset of shortness of breath (SOB) with minimal exertion while at home. The dyspnea was increasing and he decides to present to the ER.
D R B
13 02 30
ER
MACSTRAK
X
The Macstrak Project
ER Case Study
Arrives in the ER (non EMS) with persistent SOB.
X
The Macstrak Project
ER Case Study
Arrives in the ER (non EMS) with persistent SOB.
X
The Macstrak Project
ER Case Study
Triaged level III.
X
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
Nursing assessment reveals that DRB has gained 3 kg with peripheral edema over the past week and has had increasing dyspnea on exertion. Tonight, his dyspnea worsened and progressed to dyspnea at rest. He denies chest pain. On examination, his BP is 140/90 and his HR is 110. On ausculation, he has mod/severe rales bilaterally.
XX
X
The Macstrak Project
ER Case Study
Nursing assessment reveals that DRB has gained 3 kg with peripheral edema over the past week and has had increasing dyspnea on exertion. Tonight, his dyspnea worsened and progressed to dyspnea at rest. He denies chest pain. On examination, his BP is 140/90 and his HR is 110. On ausculation, he has mod/severe rales.
XX
XX
The Macstrak Project
ER Case Study17:30 DRM experiences a new onset of shortness of breath (SOB) with minimal exertion while at home.
18:30 Arrives in the ER (non EMS) with persistent SOB.
18:40 Triaged level III.
18:45 Nursing assessment reveals that DRB has gained 3 kg with peripheral edema over the past week and has had increasing dyspnea on exertion.
19:00 Seen by the ER MD who orders diuretics IV, NTG S/L, routine blood work and a chest X-ray.
17:30
18:30
18:40
18:45
19:00
The Macstrak Project
ER Case Study
ECG shows Left Bundle Branch Block (LBBB).
X
The Macstrak Project
ER Case Study
18:55 ECG shows Left Bundle Branch Block (LBBB).
18:55
18:55
The Macstrak Project
ER Case Study
Seen by the ER MD who orders diuretics IV, NTG S/L, routine bloodwork and a chest X-ray.
X
The Macstrak Project
ER Case Study
Seen by the ER MD who orders diuretics IV, NTG S/L, routine bloodwork and a chest X-ray.
X
The Macstrak Project
ER Case Study
Admitted to the ward service in stable condition with CHF.
XX
The Macstrak Project
ER Case Study
Admitted to the ward service in stable condition with CHF.
X
The Macstrak Project
ER Case Study
20:20 ER MD decides DRB should be admitted to the ward.
22:00 Admitted to the ward service in stable condition with CHF.
X
20:20
22:00