THE CASE<br /> J.M 48 y old man.<br /> R.H casuality @ 20:30.<br />C/O : upper abd pain and vomiting.<br />BP=94/67 PR=120/mnt T=37<br /> WHAT DO U WANT TO KNOW / DO?<br />
Primary Survey<br /><ul><li>Conscious and talking >>>A=patent.
B= breathing spontaneously, equal air entry , saturation in room air=96%.
C= has cold extremeties and looks dehydrated . BP=94/67 , PR=120/mnt.
D= no apparent deficit, glucose not checked, normal size and reacting pupils</li></li></ul><li> HISTORY <br />S : since morning , upper abd pain, radiating to back and retrosternally, associated with vomiting, no diarrhea, no fever.<br />A : no allergies.<br />M : not on any medications. Smoker and ethanol consumer ?? Iv drug abuser.<br />P : no past medical or surgical history.<br />L : not recalling,, vomits whatever eaten.<br />
SECONDARY SURVEY<br /><ul><li>Generally ; dehydrated, no visible veins, has tattoo , restless, poor hygiene with smell of alcohol from his mouth.
CVS; S1 S2; normal, ECG; sinus rythem , bed side troponin is negative.
ABD; soft, tender epigastrium and both hypochondria ,hernial orifices intact and normal genitalia.</li></li></ul><li> 48yr old male<br /> no medical problem<br /> smoker, alcoholic , drug addict<br /> upper abd tenderness<br />hypovolemic<br /> ECG and troponin not suggestive of ischemia<br />WHAT IS NEXT <br />WHAT IS IN UR MIND<br />
ACTIONS TAKEN<br />Labs for CBC, UE, LFT, TROPONIN, COAGULATION AND AMYLASE.<br />Received IVF 500ml, metoclopromid , ranitidine and tramal .<br />Ordered for CXR.<br />
Then what happened to J.M<br /> the treating physicians decided he is fit for discharge, so disposed home.<br />His relative asleep at home, so when contacted said will come in morning to pick him up.<br />Kept in day ward, when over taken to waiting area ,comes back to be saying he is SICK.<br />In morning, security and PRO called to do something as refused to leave the bed.<br />
When relative finally arrived, when reached the car, noticed that he is really sick and brought him back.<br />At triage the nurse asked one of u to talk to them to go home and she asked her at least get his vitals sister.<br />Finally another set of vitals which showed: PR=140/mnt<br /> BP=114/73<br /> RR= 26/mnt<br /> saturation= 91%<br />
Went to : </li></ul> ARDS<br />pneumothorax<br /> surgical emphysema from neck to scrot.<br /><ul><li>PASSED AWAY.</li></li></ul><li>Pneumonia(management)<br />Possibility of communicable disease suggest early isolation.<br />Timely administration of antimicrobials associated with improved outcome.<br />Prevalence of DRSA is increasing.<br />CA-MRSA is a cause of rapidly progressive pneumonia with sepsis<br />
Pneumonia(management)<br />Antimicrobial agent should be tailored according to :<br />Simple CAP.<br />DRSP.<br />MRSA.<br />P. aerugensa.<br />
Pneumonia (Disposition)<br />Variability in physician admission decisions.<br />No firm guidelines but scoring system assist with hospitalization decision.<br />One commonly used is the prospectively validated predictive rule of mortality<br />The pneumonia patient outcomes Research Team Study (pneumonia severity index PSI<br />
Pneumonia severity index PSI<br /> Age Male No. years of age<br /> Female No. years of age −10<br /> Nursing home resident 10<br />Comorbid illness Neoplastic disease 30<br /> Liver disease 20<br /> Congestive heart failure 10<br /> Cerebrovascular disease 10<br /> Renal disease 10<br />Physical examination finding Altered mental status 20<br /> Respiratory rate ≥ 30 20<br /> Systolic blood pressure ≤90 mm Hg 20<br /> Temperature < 35° C or > 40° C 15<br /> Pulse ≥ 125 beats/min 10<br />Laboratory or radiographic finding Arterial pH < 7.35 30<br /> Blood urea nitrogen >30 mg/dL 20<br /> Sodium <130 mEq/L 20<br /> Glucose > 250 mg/dL 10<br /> Hematocrit < 30% 10<br /> Arterial Po2< 60 mm Hg 10<br /> Pleural effusion 10<br />
PSI<br />Hospitalizations is recommended with a score greater than 91.<br />A brief admission or observation for 71-90<br />It is not modeled for to predict acute life threatening events.<br />Clinical judgment supersede strict interpretation of PSI.<br />Revealed significantly lower admissions and cost.<br />
CURB-65<br />Risk of 30 day mortality:<br /> 0 factor 0.7% (0-1 can be outpatient)<br /> 2 factors 9.2% (with 2 should admit)<br /> 5 factors 57% (3 or more consider ICU)<br />No randomized trials compared PSI vs CURB-65.<br />