Difference between revisions of "STEMI-2017/C2/Initial-Patient-Details-data-entry/English"

Initial Patient Details

• Enter initial patient details of a new patient on the STEMI App
• in case of direct entry in a STEMI A, B, C and D Hospital.
• For EMRI, the initial data entry will be different.

1. An Android tablet with STEMI App installed on it and
2. A working Internet connection

• You will also need to have working knowledge of the STEMI device and the STEMI App.
• If not, please refer to the STEMI tutorial series on this website.

• Contains basic details of the patient, Fibrinolytic checklist, Cardiac History, Co-morbid Conditions and Contact details.
• It marks the start of data entry of a new patient on admission to any Stemi Hospital.

But the narration says A/B

BASIC DETAILS

• Patient Name: Ramesh

• Age: 53

• Gender: Male

• Phone Number: 9988776655

• Address 1: X villa, X – road, Coimbatore – 000 000, Tamil Nadu

We will enter the following details here-

• Patient Name: Ramesh
• Age: 53
• Gender: Male
• Phone Number and
• Address

State BPL Insurance, Private Insurance, Self-Payment

Choose State BPL Insurance

State BPL Insurance, Private Insurance, Self-Payment

I’ll choose State BPL Insurance.

Date: 21/1/2016 Time: 9:00 am

Here we will enter the date and time when the symptoms were noticed.

I will enter the Date and the Time.

Here we will select the mode of hospital admission.

Since this is a case of direct admission to either of the A/B, C and D STEMI Hospitals, I’ll select Direct.

Drop down ECG date/ time

Date: 21/1/2016 Time: 9:20 am

If Yes , then we have the drop- down ECG Date and Time.

• STEMI Confirmed Yes

• STEMI Confirmed Date/ Time

Date: 21/1/2016 Time: 9:25am

If Yes, we will be prompted to fill the Date and Time.

• Mode of Transport to Hospital

Options –Public, GVK Ambulance, Private Ambulance,Private

Here we choose the mode of transport by which the patient arrived at the C Hospital.

Public Vehicle, GVK Ambulance, Private Ambulance, Private Vehicle

Ambulance Arrival Date & Time

Ambulance Departure Date & Time

• Ambulance Call Date & Time

• Ambulance Arrival Date & Time

• Ambulance Departure Date & Time

Text on screen

Under STEMI protocols the EMRI ambulances always shift the patient to a D or A/B Hospital.

1. Systolic BP Greater than 180 mmHg No
2. Diastolic BP Greater than 110 mmHg No
3. Right Vs Left arm Systolic BP greater than 15 mmHg No
4. Significant closed head/facial trauma within the previous  3months - No
5. Recent (within 6 weeks) major trauma, surgery (including laser eye surgery),GI/GU Bleed No
6. Bleeding or clotting problem or on blood thinners No
7. CPR greater than 10 min No
8. Serious systemic disease (e.g., advanced/terminal cancer, severe liver or kidney disease) No
9. History of structural central nervous system disease No
10. Pulmonary edema (rales greater than halfway up No
11. Systemic hypoperfusion (cool, clammy) No
12. Does the patient have severe heart failure or cardiogenic shock such that PCI is preferable such that PCI is preferable? No

There will be 13 items displayed If the patient was female.

The extra item is Pregnant Female Ye/No, which we have to fill according to the gender of the patient.

I’ll check all the 12 points as ‘No’ for this demo.

MI 1 – options:

Anterior wall, Inferior Wall, Posterior Wall, Lateral Wall, RV Infarction

Choose Anterior Wall

MI1 date : 2/1/2015

MI1 details: ________________

Under MI1, we have the options –

Anterior wall, Inferior wall, Posterior wall, Lateral wall, RV Infarction.

I’ll choose Anterior Wall.

Once we select MI 1, we further get drop-downs MI1 Date & MI 1 Details

I’ll enter the Date :

In MI1 Details, I will type “Patient was stable at the time of discharge”.

In the Duration: drop-down, select 2 years

If ‘Yes’ we then get a dropdown Duration:

Here I will select 2 years.

We have to enter the details based on the patient's past history.

CABG Select ‘Yes’

CABG Date : 7/1/2015

If Yes, enter the CABG Date:

You have to enter the date depending on whether the patient underwent CABG in the past.

PCI 1 Date : 7/1/2015

If Yes, we get a dropdown PCI 1 Date and PCI 1 Details.

Once again, you have to enter the date depending on whether the patient had a PCI done in the past.

I will enter “Stenting done”.

• Chest Discomfort : options – Pain, Pressure, Aches

Choose Pain

• Location of Pain: options – Retrosternal, Jaw, L arm, R arm. Back

Choose Retrosternal

• Pain Severity Pain scale 1 – 10

Choose 8

• Palpitation Check

• Pallor
• Diaphoresis
• Shortness of Breath Check

• Nausea/ Vomiting Check

• Dizziness: Check

• Syncope:

Under Diagnosis we have the following

• Chest Discomfort:

The options are– Pain, Pressure, Aches

I’ll choose Pain

• Location of Pain:

The options are– Retrosternal, Jaw, Left arm, Right arm, Back

I’ll choose Retrosternal

• Next we have to enter the Pain Severity:

On a scale from 1 to 10; 1 being least painful and 10 being extreme pain.

I’ll choose 8

• Palpitations :

Check this option as Yes, if there are palpitations.

Similarly for the rest, check if Yes.

I’ll check a few as Yes.

• Pallor: Yes
• Diaphoresis:
• Shortness of Breath:

Check this, if its so.

• Nausea/ Vomiting: Yes

Again check, if the same is observed.

• Dizziness: Yes

check Yes if it is so.

• Syncope:Yes

• Height (cm) 175
• Weight (kg) 80
• BMI auto populated

• BP Systolic 140
• BP Diastolic 110
• Heart Rate 82

• Height (in cm) 175
• Weight (in kg) 80
• BMI gets auto populated once height and weight are entered.

• BP Systolic 150 mm Hg
• BP Diastolic 110 mm Hg
• Heart Rate 82 beats per minute

• Smoking

Options Non Smoker, Current Smoker, Past Smoker , Unkown or Passive

Current Smoker is selected

Drop-down options

Beedies Check if smokes Cigarettes Check if smokes

Number 1 pack a day

Duration 20 yrs

Ask the patient or relatives about the patient’s smoking habits.

We have options- Non Smoker, Current Smoker, Past Smoker, Unknown and Passive

If we select Current Smoker, Past Smoker or Passive, then we get further drop- downs.

I’ll select Current Smoker

1. Beedies

   Check if the patient smokes this.

2. Cigarettes

   Check if the patient smokes this.

   I’ll check both as ’Yes’

3. In Number, enter the no. of beedies or cigarettes the patient smokes daily.

   I will enter 12.

4. Duration is where we will enter the no. of years the patient has been smoking/ or has smoked previously.

   I will enter “15 yrs”

Select Yes

Check if Yes

I’ll select Yes

Point to drop-down

Duration: 10 yrs

OHA: Glycophage Insulin: Human Actrapid

We have drop-downs Duration, OHA & Insulin

For Duration: I will enter 10 yrs.

OHA: For eg-Glycophage

Insulin:For eg- Human Actrapid

Point to drop-down

Duration: 15 yrs

We have drop-downs Duration, Medications and Medications details.

Duration: I will select 15 yrs

• Medication check if patient is on medications
• Medication details: Tenormin,Amilodipine- H

Then under Medication details: we will enter the names of some Hypertension drugs.

For eg- Tenormin, Amilodipine H, etc,.

• Medication: Check if Yes
• Medication Details; Atorvastatin

Medication & Medication Details

Medication: Check if Yes

Medication Details: For eg- Atorvastatin

Dropdown Allergy Details: dairy products

We get the drop-down Allergy details:

Here I will enter Dairy products.

Relation Name : Ramu

Relation Type: Father

Address : X villa, X road, Coimbatore, Tamil Nadu

City: Coimbatore

Contact No: Mob : 9977885566

Occupation: Driver

Aadhar Card No. XYZ001100

ID Proof: I’ll Choose Driving License

Upload Aadhar: snapshot of the Aadhar card in the device >> select browse tab >> access the image file >> save it on to the App

Relation Name : Ramu

Relation Type: We have the options Father, Spouse, Others

I’ll choose Father

Then enter the Address :

The City:

Contact No: Mobile :

Occupation:

Aadhar Card No.

ID Proof:

We have options Voter ID, Driving License, Family Card, Passport, Pan Card, Others

I’ll choose Driving License.

Upload Aadhar: Take a snapshot of the Aadhar card on the device, then select the Browse tab.

And access the image file from the gallery and save it on to the App.

Do likewise for Driving License.

This information will help us during the follow up period to get back to the patient's relative.

• Complete the data entry of a new patient on the STEMI App
• at the time of admission to any STEMI Hospital.

• was set up as a ‘not for profit’ organisation
• primarily to reduce delays in accessing appropriate care for heart attack patients
• thereby saving the lives of X% of the patients
• and reducing deaths due to heart attacks

For more details, please visit http://spoken-tutorial.org

This is Nancy Varkey IIT Bombay, signing off.

Thanks for watching.