Ward Case Studies

1. 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

2. Ward Case Study AB is a 52-year-old businessman (17/5/53) with no significant past medical history. The Macstrak Project

3. 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

4. Ward Case Study Over his course in hospital he received the following medications: At homeIn ERIn CCU No meds ASA po ASA po Metoprolol IV Metoprolol IV Nitro S/L Nitro IV Heparin IV (UFH) Heparin IV (UFH) The Macstrak Project

5. 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

6. 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

7. MACSTRAK Ward Ward Case Study Patient Initials: F M L Birth Date:19 Day Month Year Gender: Male Female A B C D Centre: Date:20 Day Month Year A B 17 05 53 X AB is a 52-year-old businessman (17/5/53) with no significant past medical history. The Macstrak Project

8. MACSTRAK Ward Ward Case Study Patient Initials: F M L Birth Date:19 Day Month Year Gender: Male Female A B C D Centre: Date:20 Day Month Year A B 17 05 53 22 03 06 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

9. Ward Case Study Past Medical History:<30 days >30 days MI ……………………………. Angina ……………………….. CABG ……………………….. PCI …………………………… CHF ………………………….. TIA/CVA …………………….. Diabetes (oral agents/insulin) ... None of the Above……………. AB is a 52-year-old businessman (17/5/53) with no significant past medical history. X The Macstrak Project

10. Ward Case Study Patient Origin: ER Dr.’s Office/Clinic (Direct) Other Acute Care Hospital Home Direct (Elective) Inpatient 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. X X The Macstrak Project

11. Admitting Diagnosis:(Check one only) Acute AMI UA R/O MI UA RSCP NYD CHF Arrhythmia Aortic Dissection Non ACS Pericardial Disease Other: ………………....… Elective: ………………… ACS Ward Case Study AB is admitted to the ward from the CCU on 22/3/06 with a diagnosis of Acute Myocardial Infarction. X The Macstrak Project

12. Ward Case Study On the morning of 20/03/06 he had an episode of painlasting 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. X X X X X X The Macstrak Project

13. 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. X X The Macstrak Project

14. Ward Case Study Over his course in hospital he received the following medications: At home: No meds 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 x x x TC TC The Macstrak Project

15. Ward Case Study 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 x x x x x KD TC TC The Macstrak Project

16. Ward Case Study 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 x x x x x KD TC TC The Macstrak Project

17. Ward Case Study 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. x x x x x x x x x x x x x KD TC TC TC The Macstrak Project

18. 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. x x TC The Macstrak Project

19. Discharge Diagnosis: Acute MI Unstable Angina Chest Pain NYD CHF Arrhythmia Aortic Dissection Pericardial Disease Other Cardiac Problem: ………….................. Non Cardiac Problem:…..….............………. Elective: ………….......................................... Ward Case Study Date: 20 26 03 06 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. Day Month Year X Peak CK: Trop: 1041 21 The Macstrak Project

20. Ward Case Study He has an uneventful stay on the ward and is dischargedhome 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. X The Macstrak Project

21. Discharge Diagnosis: Acute MI Unstable Angina Chest Pain NYD CHF Arrhythmia Aortic Dissection Pericardial Disease Other Cardiac Problem: ………….................. Non Cardiac Problem:…..….............………. Elective: ………….......................................... Ward Case Study Date: 20 26 03 06 DG is discharged home on 14/3/06 on ASA po, metropolol po, furosemide and an ACE Inhibitor. His final diagnosis is CHF. Day Month Year Peak CK: Trop: X The Macstrak Project