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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
Ward Case Study
The Macstrak Project
Ward Case Study
DG is an 82-year-old (02/3/24) retiree with a past medical history
of an anterior MI in 1990, and admission for mild CHF in 1992 and
hypertension. He is on metropolol and ASA.
The Macstrak Project
Ward Case Study
DG is an 82-year-old (02/3/24) retiree with a past medical history
of an anterior MI in 1990, and admission for mild CHF in 1992 and
hypertension. He is on metropolol and ASA.
DG awoke on the morning of 10/03/06 with mild shortness of
breath and chest congestion. As the day wore on his shortness
of breath and chest congestion worsened and he presented to
the ER of his local hospital in the late afternoon.
The Macstrak Project
Ward Case Study
In the ER, on examination, he is found to be moderately dyspneic
with crackles bilaterally throughout his lung fields, BP 166/68, and
HR 96. He denies having any chest pain. While in the ER he
receives furosemide IV and O2 at 40 % via mask. A CXR shows
moderate cardiomegaly and interstitial pulmonary edema.
The Macstrak Project
Ward Case Study
He is admitted to the ward with an admitting diagnosis of CHF.
Shortly after admission DG states that his shortness of breath is
much improved. On day 1, his O2 is discontinued, his metoprolol
dose is reduced and he starts on an ACE Inhibitor. He continues on
these medications as well as ASA and furosemide while he is on the
ward. He has an echocardiogram on day 3 which shows anterior
akinesis but no valvular adnormalities.
DG is discharged home on 14/3/06 on ASA po, metropolol po,
furosemide and an ACE Inhibitor. His final diagnosis is CHF.
The Macstrak Project
Ward Case Study
MACSTRAK
Patient Initials: D
F
Birth Date:
Ward
Gender:
G
M
02
03
Day
Month
X Male
A
Centre:
B
C
D
L
19 24
Year
Date:
20
Day
Month
Year
Female
DG is an 82-year-old (02/3/24) retiree with a past medical history
of an anterior MI in 1990, and admission for mild CHF in 1992
and hypertension. He is on metropolol and ASA.
The Macstrak Project
Ward Case Study
MACSTRAK
Patient Initials: D
F
Birth Date:
Ward
Gender:
G
M
02
03
Day
Month
X Male
A
Centre:
B
C
D
L
19 24
Year
Date:
10
03
Day
Month
20 06
Year
Female
DG awoke on the morning of 10/03/06 with mild shortness of
breath and chest congestion. As the day wore on his shortness of
breath and chest congestion worsened and he presented to the ER
of his local hospital in the late afternoon.
The Macstrak Project
Ward Case Study
Past Medical History:
<30 days
MI …………………………….
Angina ………………………..
CABG ………………………..
PCI ……………………………
CHF …………………………..
TIA/CVA ……………………..
Diabetes (oral agents/insulin) ...
None of the Above…………….
>30 days
X
X
DG is an 82-year-old
(02/3/24) retiree with a
past medical history of an
anterior MI in 1990, and
admission for mild CHF
in 1992 and hypertension.
He is on metropolol and
ASA.
The Macstrak Project
Ward Case Study
Patient Origin:
X ER
Dr.’s Office/Clinic (Direct)
Other Acute Care Hospital
Home Direct (Elective)
Inpatient
CCU
Other ICU
Other Ward
Other: ………………
In the ER, on examination, he is found
to be moderately dyspneic with crackles
bilaterally throughout his lung fields,
BP 166/68, and HR 96. He denies
having any chest pain. While in the ER
he receives furosemide IV and O2 at 40
% via mask. A CXR shows moderate
cardiomegaly and interstitial pulmonary
edema.
He is admitted to the ward with an
admitting diagnosis of CHF.
The Macstrak Project
Ward Case Study
Admitting Diagnosis: (Check one only)
Acute AMI
UA R/O MI
ACS
UA
RSCP NYD
X CHF
Arrhythmia
Aortic Dissection
Non ACS
Pericardial Disease
Other: ………………....…
Elective: …………………
He is admitted to the ward with an
admitting diagnosis of CHF.
The Macstrak Project
Ward Case Study
ACS: X No
Chest Pain:
Yes
(Probable ischemia only)
If Yes
Episodes
Yes No
Prolonged*
Troponin
Yes No
NotDone Pos Neg
Prior to Ward 0-6 hrs ………
Prior to Ward 6-24 hrs …..
Prior to Ward 1-7 days …..
He is admitted to the ward with
an admitting diagnosis of CHF.
* (> 15 min)
The Macstrak Project
Ward Case Study
Drugs:
PTA
PTW Ward Disch
ASA ……………………………………………………. x
Coumadin ……………………………………….
Heparin UFH…………………………….
Heparin LMWH…………………………
Clopidogrel (or ticlopidine) ……..…….
GP 2b/3a Inhibitor (IV)……………
Other Antithrombin …….……………
Oral Hypoglycemic …………………
Insulin ……………………………………………….
Statin ………………………………………………….
Other Antilipid …………………………...
Bronchodilator ……………………………
Digoxin …………………………………………….
Any Antiarrhythmic ……………….
Calcium Antag ……………………………
ACEI .……………………………………………………
A2 blocker ……………………………………….
Other Vasodilator ……...……………….
Diuretic ……………………….……………………...
Nitrates top/oral …………………………..
Nitrates IV ……………………………….……...
 Blocker - Any…………………………... x
 Blocker - Carvedilol …………...
Study Drug - antiplatelet …...
- antithrombin .
- other ………………….
Smoking …………………………………………..
HRT …………………………………………………….
DG is an 82-year-old (02/3/24)
retiree with a past medical history of
an anterior MI in 1990, and
admission for mild CHF in 1992 and
hypertension. He is on metropolol
and ASA.
……………………………..…..
……………………………..…..
Optional Fields:
Crs1: ……………………………..
Crs2: ……………………………..
Crs3: ……………………………..
Crs4: ……………………………..
None of the Above …………………..
RN Initials …………………………………….. TC
The Macstrak Project
Ward Case Study
Drugs:
PTA
PTW Ward Disch
ASA ……………………………………………………. x
Coumadin ……………………………………….
Heparin UFH…………………………….
Heparin LMWH…………………………
Clopidogrel (or ticlopidine) ……..…….
GP 2b/3a Inhibitor (IV)……………
Other Antithrombin …….……………
Oral Hypoglycemic …………………
Insulin ……………………………………………….
Statin ………………………………………………….
Other Antilipid …………………………...
Bronchodilator ……………………………
Digoxin …………………………………………….
Any Antiarrhythmic ……………….
Calcium Antag ……………………………
ACEI .……………………………………………………
A2 blocker ……………………………………….
Other Vasodilator ……...……………….
Diuretic ……………………….……………………...
Nitrates top/oral …………………………..
Nitrates IV ……………………………….……...
 Blocker - Any…………………………... x
 Blocker - Carvedilol …………...
Study Drug - antiplatelet …...
- antithrombin .
- other ………………….
Smoking …………………………………………..
HRT …………………………………………………….
x
In the ER, on examination, he is
found to be moderately dyspneic
with crackles bilaterally throughout
his lung fields, BP 166/68, and HR
96. He denies having any chest pain.
While in the ER he receives
furosemide IV and O2 at 40 % via
mask. A CXR shows moderate
cardiomegaly and interstitial
pulmonary edema.
……………………………..…..
……………………………..…..
Optional Fields:
Crs1: ……………………………..
Crs2: ……………………………..
Crs3: ……………………………..
Crs4: ……………………………..
None of the Above …………………..
RN Initials …………………………………….. TC
TC
The Macstrak Project
Ward Case Study
Drugs:
PTA
PTW Ward Disch
ASA ……………………………………………………. x
Coumadin ……………………………………….
Heparin UFH…………………………….
Heparin LMWH…………………………
Clopidogrel (or ticlopidine) ……..…….
GP 2b/3a Inhibitor (IV)……………
Other Antithrombin …….……………
x
Oral Hypoglycemic …………………
Insulin ……………………………………………….
Statin ………………………………………………….
Other Antilipid …………………………...
Bronchodilator ……………………………
Digoxin …………………………………………….
Any Antiarrhythmic ……………….
Calcium Antag ……………………………
ACEI .……………………………………………………
A2 blocker ……………………………………….
Other Vasodilator ……...……………….
Diuretic ……………………….……………………...
Nitrates top/oral …………………………..
Nitrates IV ……………………………….……...
 Blocker - Any…………………………... x
 Blocker - Carvedilol …………...
Study Drug - antiplatelet …...
- antithrombin .
- other ………………….
Smoking …………………………………………..
HRT …………………………………………………….
x
x
x
x
……………………………..…..
……………………………..…..
Optional Fields:
Crs1: ……………………………..
Crs2: ……………………………..
Crs3: ……………………………..
Crs4: ……………………………..
Shortly after admission DG states that
his shortness of breath is much
improved. On day 1, his O2 is
discontinued, his metoprolol dose is
reduced and he starts on an ACE
Inhibitor. He continues on these
medications as well as ASA and
furosemide while he is on the ward.
He has an echocardiogram on day 3
which shows anterior akinesis but no
valvular adnormalities.
None of the Above …………………..
RN Initials …………………………………….. TC
TC KD
The Macstrak Project
Ward Case Study
Drugs:
PTA
PTW Ward Disch
ASA ……………………………………………………. x
Coumadin ……………………………………….
Heparin UFH…………………………….
Heparin LMWH…………………………
Clopidogrel (or ticlopidine) ……..…….
GP 2b/3a Inhibitor (IV)……………
Other Antithrombin …….……………
x
x
x
x
x
x
x
x
Oral Hypoglycemic …………………
Insulin ……………………………………………….
Statin ………………………………………………….
Other Antilipid …………………………...
Bronchodilator ……………………………
Digoxin …………………………………………….
Any Antiarrhythmic ……………….
Calcium Antag ……………………………
ACEI .……………………………………………………
A2 blocker ……………………………………….
Other Vasodilator ……...……………….
Diuretic ……………………….……………………...
Nitrates top/oral …………………………..
Nitrates IV ……………………………….……...
 Blocker - Any…………………………... x
 Blocker - Carvedilol …………...
Study Drug - antiplatelet …...
- antithrombin .
- other ………………….
Smoking …………………………………………..
HRT …………………………………………………….
x
……………………………..…..
……………………………..…..
Optional Fields:
Crs1: ……………………………..
Crs2: ……………………………..
Crs3: ……………………………..
Crs4: ……………………………..
None of the Above …………………..
RN Initials …………………………………….. TC
Shortly after admission DG states that his
shortness of breath is much improved.
On day 1, his O2 is discontinued, his
metoprolol dose is reduced and he starts
on an ACE Inhibitor. He continues on
these medications as well as ASA and
furosemide while he is on the ward. He
has an echocardiogram on day 3 which
shows anterior akinesis but no valvular
adnormalities.
TC KD KD
DG is discharged home on 14/3/06 on
ASA po, metropolol po, furosemide and
an ACE Inhibitor.
The Macstrak Project
Ward Case Study
Events:
Ward
Telemetry ……………………………………………
RSCP - ischemia - definite …..
- probable ..
Code ……………………………………………………….
Sustained SVT (no code) …………
Sustained VT (no code) …………….
(1)
CVA* ……………………………………………….
(2)
Major Bleed* ……………………………..
Transfusion ……………………………………….
Coronary Angiography ………….
PCI ………..………………………………………………….
Exercise Test …………………………………...
Exercise Test with image ……….
Drug Stress Test with image .
Echocardiogram …………………………… x
RNA for LVEF ………........................…….
LVEF < 40% (nuc/echo)………….
Other Cardiac Imaging …………….
Non Cardiac Imaging ……………….
Research (randomised) ......………………..
Shortly after admission DG states
that his shortness of breath is much
improved. On day 1, his O2 is
discontinued, his metoprolol dose is
reduced and he starts on an ACE
Inhibitor. He continues on these
medications as well as ASA and
furosemide while he is on the ward.
He has an echocardiogram on day
3 which shows anterior akinesis but
no valvular adnormalities.
Crs5: ………………………………..
Crs6: ………………………………..
Crs7: ………………………………..
Crs8: ………………………………..
None of the Above ……………………...
RN Initials ………………………………………... TC
The Macstrak Project
Ward Case Study
03
Date: 26
Day
Month
06
20 Year
Discharge Diagnosis:
Acute MI
Peak CK:
Unstable Angina
Trop:
Chest Pain NYD
X CHF
Arrhythmia
Aortic Dissection
Pericardial Disease
Other Cardiac Problem: …………..................
Non Cardiac Problem: …..….............……….
Elective: …………..........................................
DG is discharged home on
14/3/06 on ASA po,
metropolol po, furosemide and
an ACE Inhibitor. His final
diagnosis is CHF.
The Macstrak Project
Ward Case Study
Discharge To: (Check one only)
X Home
CCU
Other ICU
OR for CV Surgery
OR for Other Surgery
Death
Medical ward
Surgical Ward
Rehab/Chronic Care Hosp
Other Acute Care Hosp
Other…………………………….
DG is discharged home on
14/3/06 on ASA po,
metropolol po, furosemide and
an ACE Inhibitor. His final
diagnosis is CHF.
The Macstrak Project