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ER Case Studies

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.

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ER Case Studies

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  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 DRB is a 76 year old male (13/02/30) who had a large anterior infarction 3 years ago. The Macstrak Project

  4. 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: 17:30 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. The Macstrak Project

  5. ER Case Study 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. 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

  6. ER Case Study 18:55 ECG shows Left Bundle Branch Block (LBBB). 19:00 Seen by the ER MD who orders diuretics IV, NTG S/L, routine bloodwork and a chest X-ray. 19:15 Chest X-ray confirms pulmonary edema. 20:15 DRB’s dyspnea improves following diuresis. The Macstrak Project

  7. 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. The Macstrak Project

  8. 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 D R B 13 02 30 X DRB is a 76 year old male (13/02/30) who had a large anterior infarction 3 years ago. 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:15 0320 06 Day Month Year D R B 13 02 30 X 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. The Macstrak Project

  10. ER Case Study Arrives in the ER (non EMS) with persistentSOB. X The Macstrak Project

  11. ER Case Study Arrives in the ER (non EMS) with persistent SOB. X The Macstrak Project

  12. ER Case Study Triaged level III. X The Macstrak Project

  13. 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. 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

  14. 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. X X X X The Macstrak Project

  15. ER Case Study 17:30 DRM experiences a new onset of shortness of breath (SOB) with minimal exertion while at home. 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. 19:00Seen 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

  16. ER Case Study ECG shows Left Bundle Branch Block (LBBB). X The Macstrak Project

  17. ER Case Study 18:55 ECG shows Left Bundle Branch Block (LBBB). 18:55 18:55 The Macstrak Project

  18. 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

  19. 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

  20. ER Case Study Admitted to the ward service in stable condition with CHF. X X The Macstrak Project

  21. ER Case Study Admitted to the ward service in stable condition with CHF. X The Macstrak Project

  22. 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. 20:20 22:00 X The Macstrak Project

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