CCU Case Studies

1
CCU 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 patients 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.
2
CCU Case Study
3
CCU Case Study
FR is an 86-year-old (DOB 23/01/20) man with a
past medical history of MIs in 1990 and 1994 and
2 episodes of CHF in 1995 as well as a three-day
hospitalization three weeks ago for CHF.
4
CCU Case Study
FR is an 86-year-old (DOB 23/01/20) man with a
past medical history of MIs in 1990 and 1994 and
2 episodes of CHF in 1995 as well as a three-day
hospitalization three weeks ago for CHF.
On 02/03/06 FR presented to the ER with dyspnea
at rest and was admitted to the ward service with
CHF. He received ASA, an ACE inhibitor and
furosemide.
5
CCU Case Study
FR is an 86-year-old (DOB 23/01/20) man with a
past medical history of MIs in 1990 and 1994 and
2 episodes of CHF in 1995 as well as a three-day
hospitalization three weeks ago for CHF.
On 02/03/06 FR presented to the ER with dyspnea
at rest and was admitted to the ward service with
CHF. He received ASA, an ACE inhibitor and
furosemide.
The morning of 06/03/06 he becomes increasingly
short of breath. He has severe chest congestion.
Two hours later he is in acute distress. His BP
is 78/42 and HR is 120. He denies any chest pain.
He is transferred to the CCU with a diagnosis of
CHF.
6
CCU Case Study
FR arrives in the CCU at 1030 a.m. He is
intubated and ventilated and given dopamine IV.
He has an arterial line placed and remains
hypotensive despite increasing amounts of
dopamine. He also receives furosemide IV. A PA
line is placed and confirms an elevated wedge
pressure at 28 mmHg and low cardiac output at 3.2
litres/min. At 1330 he has a VT/VF arrest and
is promptly defibrillated. He remains
hypotensive and anuric and dies of progressive
hypotension at 1830. His discharge diagnosis is
CHF.
7
CCU Case Study
      Patient Initials F
M L   Birth Date
19  


Day Month
Year   Gender Male
Female
    Centre CCU ICU
        Date
20 Day
Month Year
F R
23 01 20
X
FR is an 86-year-old (DOB 23/01/20) man with a
past medical history of MIs in 1990 and 1994 and
2 episodes of CHF in 1995 as well as a three-day
hospitalization three weeks ago for CHF.
8
CCU Case Study
      Patient Initials F
M L   Birth Date
19  


Day Month
Year   Gender Male
Female
    Centre CCU ICU
        Date
20 Day
Month Year
F R
23 01 20
06 03 06
X
The morning of 06/03/06 he becomes increasingly
short of breath. He has chest congestion. Two
hours later he is in acute distress. His BP is
78/42 and HR is 120. He denies any chest pain.
He is transferred to the CCU with a diagnosis of
CHF.
9
CCU Case Study
Past Medical History lt30 days gt30
days MI . Angina .. CABG
.. PCI CHF
.. TIA/CVA .. Diabetes (oral
agents/insulin) ... None of the Above.
FR is an 86-year-old (DOB 23/01/20) man with a
past medical history of MIs in 1990 and 1994 and
2 episodes of CHF in 1995 as well as a three-day
hospitalization three weeks ago for CHF.
X
X
X
10
CCU Case Study
Patient Origin ER EMS
Walk In Dr.s Office/Clinic (Direct)
Other Hospital Inpatient Medical
Ward Surgical Ward Other ICU
Other
On 02/03/06 FR presented to the ED with dyspnea
at rest and was admitted to the ward service with
CHF. He received ASA, an ACE inhibitor and
furosemide.
X
X
11
CCU Case Study
The morning of 06/03/06 he becomes increasingly
short of breath. He has severe chest congestion.
Two hours later he is in acute distress. His BP
is 78/42 and HR is 120. He denies any chest pain.
He is transferred to the CCU with a diagnosis of
CHF.
VS at Presentation (complete for all patients)
Dyspnea/Rales None Mild Mod/Severe
Systolic BP lt 100 101-130 131-160
161-190 gt190 Heart Rate lt 80
80-100 gt100
X
X
X
12
CCU Case Study
The morning of 06/03/06 he becomes increasingly
short of breath. He has severe chest congestion.
Two hours later he is in acute distress. His BP
is 78/42 and HR is 120. He denies any chest pain.
He is transferred to the CCU with a diagnosis of
CHF.
X
13
CCU Case Study
Date
FR arrives in the CCU at 1030. He is intubated
and ventilated and given dopamine IV. He has an
arterial line placed and remains hypotensive
despite increasing amounts of dopamine. He also
receives furosemide IV. A PA line is placed and
confirms an elevated wedge pressure at 28 mmHg
and low cardiac output at 3.2 litres/min. At
1330 he has a VT/VF arrest and is promptly
defibrillated.
06
D
N
D
N
N
D
Acuity Shift
X
X
X
X
X
KD
14
CCU Case Study
At 1330 he has a VT/VF arrest and is promptly
defibrillated. He remains hypotensive and anuric
and dies of progressive hypotension at 1830.
His discharge diagnosis is CHF.
Date 20
Time
06 03
06
1830
  Day
Month Year
Peak CK Trop
X
15
CCU Case Study
At 1330 he has a VT/VF arrest and is promptly
defibrillated. He remains hypotensive and anuric
and dies of progressive hypotension at 1830.
His discharge diagnosis is CHF.
Discharged To Cardiac Ward Med/Surg
Ward Step Down Unit CV Surgery
Other ICU Other Hospital Home
Death Other..............
Discharge Meds ASA Clopidogrel (or
ticlop.) Heparin (UF or LMW) Nitrates
(po/top) B Blocker ACEI A2
Blocker Statin None of Above
X
X