CASE PRESENTATION      <br />                                Dr. Raihana Al-Anqoudi<br />
OUTLINE<br />Saying HELLO.<br />The case.<br />The topic.(Management & Disposition)<br />Take home messages.<br />
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     ...
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  ...
      SECONDARY SURVEY<br /><ul><li>Generally ; dehydrated, no visible veins, has tattoo , restless, poor hygiene with sme...
Head and Neck ; even jugular gone.!!!
CHEST; clear.
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>     ...
         ACTIONS TAKEN<br />Labs for CBC, UE, LFT, TROPONIN, COAGULATION AND AMYLASE.<br />Received IVF 500ml, metocloprom...
     Labs Results<br />Troponin negative.<br />Coagulation within normal<br />Amylase within normal<br />LFT : bilirubin 7...
Labs Results<br /><ul><li>CBC :   Hb=14.7</li></ul>                 PLT=170<br />                 WBC=23.8   with N=19.7<b...
Then what happened to J.M<br /> the treating physicians decided he is fit for discharge, so disposed home.<br />His relati...
When relative finally arrived, when reached the car, noticed that he is really sick and brought him back.<br />At triage t...
<ul><li>Kept in monitor bed.
IV line put by anesthetist, given IVF.</li></ul>moxifloxacillin,tazocin and cotrimoxazole<br /><ul><li>Immediate medical r...
Admitted to HD, then shifted to ICU.
Went to :     </li></ul>     ARDS<br />pneumothorax<br />  surgical emphysema from neck to scrot.<br /><ul><li>PASSED AWAY...
Pneumonia(management)<br />Antimicrobial agent should be tailored according to :<br />Simple CAP.<br />DRSP.<br />MRSA.<br...
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Case presentation (2)

  1. 1. CASE PRESENTATION <br /> Dr. Raihana Al-Anqoudi<br />
  2. 2. OUTLINE<br />Saying HELLO.<br />The case.<br />The topic.(Management & Disposition)<br />Take home messages.<br />
  3. 3. 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 />
  4. 4. Primary Survey<br /><ul><li>Conscious and talking >>>A=patent.
  5. 5. B= breathing spontaneously, equal air entry , saturation in room air=96%.
  6. 6. C= has cold extremeties and looks dehydrated . BP=94/67 , PR=120/mnt.
  7. 7. 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 />
  8. 8. SECONDARY SURVEY<br /><ul><li>Generally ; dehydrated, no visible veins, has tattoo , restless, poor hygiene with smell of alcohol from his mouth.
  9. 9. Head and Neck ; even jugular gone.!!!
  10. 10. CHEST; clear.
  11. 11. CVS; S1 S2; normal, ECG; sinus rythem , bed side troponin is negative.
  12. 12. 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 />
  13. 13. 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 />
  14. 14.
  15. 15. Labs Results<br />Troponin negative.<br />Coagulation within normal<br />Amylase within normal<br />LFT : bilirubin 72<br /> ALP=173 ALT=68<br /> ALB=27<br />
  16. 16. Labs Results<br /><ul><li>CBC : Hb=14.7</li></ul> PLT=170<br /> WBC=23.8 with N=19.7<br /><ul><li>UE : Na= 134</li></ul> K= 4.4<br /> CO2= 21<br />Cl=100<br /> Urea= 14.6<br />Creat= 160<br />
  17. 17. 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 />
  18. 18. 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 />
  19. 19. <ul><li>Kept in monitor bed.
  20. 20. IV line put by anesthetist, given IVF.</li></ul>moxifloxacillin,tazocin and cotrimoxazole<br /><ul><li>Immediate medical review.
  21. 21. Admitted to HD, then shifted to ICU.
  22. 22. 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 />
  23. 23. Pneumonia(management)<br />Antimicrobial agent should be tailored according to :<br />Simple CAP.<br />DRSP.<br />MRSA.<br />P. aerugensa.<br />
  24. 24.
  25. 25. 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 />
  26. 26. 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 />
  27. 27. 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 />
  28. 28. CURB-65 rule<br />Another tool, easier to use.<br />Confusion..<br />Ureamia (urea > 20mg/dl)<br />RR > 30<br />BP , systolic < 90,, diastolic > 60<br />Age 65 or greater.<br />
  29. 29. 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 />
  30. 30. TAKEHOME SMS <br />

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