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 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
ER Case Study
3
ER Case Study
MBG is a 55 year old male (17/9/50) with no known
past medical history. On 10/2/06 1410 MBG
experiences gradual onset of chest pain
accompanied by a burning sensation and
nausea.
4
ER Case Study
1515 Arrives at the ER from work (non EMS) and
triaged at level II to the cardiac
room. 1520 Nursing assessment reveals
persistent midsternal chest pain with a burning
sensation and nausea. MBG has had no episodes
in the last 24 hours other than his symptoms on
presentation. He has, however, experienced the
same symptoms 4 or 5 times in the past week but
never lasting longer that 10 minutes. He is a
nonsmoker and has no history of hypertension.
His cholesterol was normal 6 months ago. MBG
has 4 older brothers, each free of heart
disease. On examination, his BP is 138/70 and
his HR is 84. His chest is clear. He is given
ASA po.
5
ER Case Study
1527 1st ECG is normal (No ACS
ST-T). 1530 Seen by an ER MD who finds that
MBGs chest pain has resolved. The ER MD
orders and IV at TKVO, cardiac bloodwork
(including troponin and CK) and and a chest
X- ray. 1540 The ER MD decided to keep MBG in
the ER for observation. 2015 Repeat ECG and
cardiac enzymes are normal, troponin is
negative and CK is normal.
6
ER Case Study
2130 MBG is discharged home in stable condition
with a diagnosis of retrosternal chest pain not
yet diagnosed (RSCP NYD) to be followed up by
family physician. (Follow up booked.)
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ER Case Study
      Patient Initials F
M L   Birth Date
19  


Day Month
Year   Gender Male
Female
    Centre         Date
20
Day Month
Year
M B G
17 09 50
X
MBG is a 55 year old male (17/9/50) with no known
past medical history.
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ER Case Study
      Patient Initials F
M L   Birth Date
19  


Day Month
Year   Gender Male
Female
    Centre         Date
10 02 20 06
Day Month
Year
M B G
17 09 50
X
MBG is a 55 year old male (17/9/50) with no known
past medical history. On 10/2/06 MBG
experiences gradual onset of chest pain
accompanied by a burning sensation and nausea.
9
ER Case Study
Nursing assessment reveals persistent midsternal
chest pain with a burning sensation and nausea.
X
Nausea
X
10
ER Case Study
Arrives at the ER from work (non EMS) and triaged
at level II to the cardiac room.
X
11
ER Case Study
Arrives at the ER from work (non EMS) and triaged
at level II to the cardiac room.
X
12
ER Case Study
Nursing assessment reveals persistent midsternal
chest pain with a burning sensation and nausea.
MBG has had no episodes in the last 24 hours
other than his symptoms on presentation. He has,
however, experienced the same symptoms 4 or 5
times in the past week but never lasting longer
that 10 minutes. He is a nonsmoker and has no
history of hypertension. His cholesterol was
normal 6 months ago. MBG has 4 older brothers,
each free of heart disease. On examination, his
BP is 138/70 and his HR is 84. His chest is
clear. He is given ASA po.
VS at Presentation VS Absent
Systolic BP Dyspnea/Rales lt 100
None 101-130 Mild 131-160
Mod/Severe 161-190 gt190 Heart
Rate lt 60 61-80 81-100
gt100
X
X
X
13
ER Case Study
Nursing assessment reveals persistent midsternal
chest pain with a burning sensation and nausea.
MBG has had no episodes in the last 24 hours
other than his symptoms on presentation. He has,
however, experienced the same symptoms 4 or 5
times in the past week but never lasting longer
that 10 minutes. He is a nonsmoker and has no
history of hypertension. His cholesterol was
normal 6 months ago.
X
X
X
X
X
X
14
ER Case Study
1410 MBG experiences gradual onset of chest
pain accompanied by a burning sensation and
nausea. 1515 Arrives at the ER from work (non
EMS) and triaged at level II to the cardiac
room. 1520 Nursing assessment reveals
persistent midsternal chest pain with a burning
sensation and nausea. 1530 Seen by an ER MD
who finds that MBGs chest pain has resolved.
1410
1515
1515
1520
1530
15
ER Case Study
1st ECG is normal (No ACS ST-T).
X
16
ER Case Study
1527 1st ECG is normal (No ACS ST-T).
1527
1527
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ER Case Study
Repeat ECG and cardiac enzymes are normal,
troponin is negative and CK is normal.
X
18
ER Case Study
Nursing assessment reveals persistent midsternal
chest pain with a burning sensation and nausea.
He is a nonsmoker and has no history of
hypertension. His cholesterol was normal 6
months ago. MBG has 4 older brothers, each free
of heart disease. On examination, his BP is
138/70 and his HR is 84. His chest is clear. He
is given ASA po.
X
19
ER Case Study
MBG is discharged home in stable condition with a
diagnosis of retrosternal chest pain not yet
diagnosed (RSCP NYD) to be followed up by family
physician. (Follow up booked.)
X
20
ER Case Study
MBG is discharged home in stable condition with a
diagnosis of retrosternal chest pain not yet
diagnosed (RSCP NYD) to be followed up by family
physician. (Follow up booked.)
X
21
ER Case Study
2130 MBG is discharged home in stable condition
with a diagnosis of retrosternal chest pain not
yet diagnosed (RSCP NYD) to be followed up by
family physician. (Follow up booked.)
2130
X