- Acute pancreatitis has varying levels of severity from mild to severe cases with high mortality. Nonoperative management is the mainstay involving fluid resuscitation, nutritional support, symptomatic treatment, and monitoring for complications.
- In severe cases, aggressive fluid resuscitation is important to prevent shock while enteral nutrition via nasogastric or nasojejunal tubes is preferred over total parenteral nutrition or prolonged nil per os.
- ERCP is indicated for cholangitis or significant biliary obstruction but not for mild biliary pancreatitis without obstruction. Infected necrosis is best drained after 4 weeks to allow development of fibrous walls.
Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...Jibran Mohsin
This Presentation focuses on definition, new classification, different scoring systems for severity, rationale for radiological signs and new management recommendations as per 2013 American College of Gastroenterology guidelines
Acute kidney injury (AKI) is a potentially life-threatening
syndrome that occurs primarily in hospitalized patients
and frequently complicates the course of critically ill
patient.
Acute Kidney Injury is is (abrupt) reduction in kidney functions as evidence by changed in laboratory values; serum creatinine, blood urea nitrogen(BUN)and urine output
Acute pancreatitis atlanta classification & managementSeneeth Peramuna
Acute Pancreatitis
Definition,
Etialogy and pathogenesis
Atlanta Revised classification
Initial risk assesment
Management of general condition, local and systemic complications
BISAP score
Modified Marshall score
Gastrointestinal bleeding (GI bleed), also known as gastrointestinal hemorrhage, is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...Jibran Mohsin
This Presentation focuses on definition, new classification, different scoring systems for severity, rationale for radiological signs and new management recommendations as per 2013 American College of Gastroenterology guidelines
Acute kidney injury (AKI) is a potentially life-threatening
syndrome that occurs primarily in hospitalized patients
and frequently complicates the course of critically ill
patient.
Acute Kidney Injury is is (abrupt) reduction in kidney functions as evidence by changed in laboratory values; serum creatinine, blood urea nitrogen(BUN)and urine output
Acute pancreatitis atlanta classification & managementSeneeth Peramuna
Acute Pancreatitis
Definition,
Etialogy and pathogenesis
Atlanta Revised classification
Initial risk assesment
Management of general condition, local and systemic complications
BISAP score
Modified Marshall score
Pancreatitis is a dreaded condition associated with development of acute and sudden inflammation of the pancreas.
Pancreatic enzymes are released in the abdomen and cause inflammation by the damage from digestion of normal body structures, especially fat in the abdomen.
Mortality ranges from 3 percent in patients with interstitial edematous pancreatitis to 17 percent in patients who develop pancreatic necrosis.
2 cases of colorectal trauma - one due to blunt trauma abdomen and one due to penetrating trauma to rectum are discussed in the light of colorectal trauma
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
3. • Acute pancreatitis – disease of high morbidity and motality
• Mortality • Mild cases : ~1%
• Severe cases : (10-30)%
EVIDENCE BASED
APPROACH
4. GUIDELINES
• Atlanta
• British Society of Gastroenterology
• American College of Gastroenterology
• International Association of Pancreas
• Santorini Conference
• World Congress of Gastroenterology
5. Risk factor assessment
Clinical risk stratification
Monitoring response
To initial therapy
3D Approach towards management
of acute pancreatitis
6. • Risk stratification Mild cases – general ward
Severe cases – Always in ICU setting
Strategy tailoring according to :
•Severity
•Risk factors (eg: age,obesity)
•Presence of SIRS
•Routine lab values(Hct, Ser.creatinine )
NONOPERATIVE MANAGEMENT IS THE MAINSTAY
7. PRINCIPLES of Management :
Fluid resuscitation
Nutritional Support
Symptomatic Treatment
Management of Metabolic Complications
Prophylactic Antibiotic Coverage
Monitoring and Reassessment
Role of ERCP
Role of surgery
8. FLUID RESUSCITATION
• Approach : Aggressive fluid resuscitation
• Amount of fluid required : (250-500) ml/hr [acc. to AGC guidelines ]
or
(5-10) ml/kg/hr [acc. to IAP guidelines ]
• Ideal fluid : Isotonic crystalloids – RINGER LACTATE
In severe volume depletion -20ml/kg over 30 min
followed by
3ml/kg/hr for (8-12) hrs
9. • Goal : Reduction in BUN
IAP suggested resuscitation goals :
* HR < 120 bpm
*MAP : ( 65-85 )mm of Hg
*Urine output > ( 0.5-1) ml/kg/hr
*Hematocrit ( 35-44 )% ( one of the best indicators of survival )
• Importance :
* Prevention of acute pancreatitis induced hypovolaemic shock
* Inadequate resuscitation – increased chance of necrosis
* Most beneficial over first 12-24 hrs
• EXCEPTIONS : Pre-existing CARDIOVASCULAR and RENAL comorbidities
10. Acute pancreatitis
Third space fluid loss
HYPOVOLEMIC SHOCK
Reduced pancreatic microcirculation Acute renal insufficency
Pancreatic Necrosis
MULTIPLE ORGAN FAILURE
( Early inflammatory phase )
11. NUTRITIONAL SUPPORT
• Different school of thoughts –
1. Continue oral feeding
2. Nil per oral
3. Nasojejunal tube feeding
4. Nasogastric tube feeding
5. Total parenteral nutrition
12. 1. Oral feeding : continuation of oral feeding may not be
possible due to - * Aggravasion of pain after oral intake
* Nausea and recurrent vomiting
* Preexisting abdominal distension caused by ileus
• In mild AP, oral feedings can be started immediately if
• In mild AP, initiation of feeding with a low-fat solid diet
appears as safe as a clear liquid diet (Level II evidence)
There is no nausea and vomiting, and
Abdominal pain has resolved
(level II evidence)
13. 2.Nil per oral :The traditional school of thought
Rationale for:
1. Avoidance of oral intake prevents stimulation of exocrine pancreatic
functions Pancreatic rest
2. Patient often unable to retain oral feed.
3. Ileus resulting from pancreatitis.
Rationale against:
1. Acute pancreatitis – inflammatory stress -
2. Prolonged avoidance of enteral feeding – altered gut mucosal integrity –
increased chance of infection.
14. 3. Total Parenteral Nutrition :
Rationale for :
• Maintenance of proper nutrition avoiding gastrointestinal complications
Rationale against :
• Increased chance of altered gut mucosal integrity
• Acts as a portal for introduction of additional infection
• Increased expenses
4. Nasogastric and 5. Nasojejunal Tube Feeding :
• Maintenance of Nutrition Enterally avoiding the gastrointestinal complications
Of both NPM and TPN
• Low expenses
Rationale against :
• Not applicable in patiens with Ileus
15. Latest Recommendations :
• Strict limitation of enteral nutrition is unnecessary
Nasojejunal tube feeding not better than Nasogastric tube feeding
Jejunal tube feeding only in patients unable to resume enteral feed early
TPN not required unless severely debilitated patient
In case TPN or tube feeding required , resume oral feed as soon as pain disappears
and patient is able to retain feed ( generally 3-7 days in mild disease)
Suggested addition of Lactobacillus sp. Preparations to enteral feed may reduce
infective complications of acute pancreatitis
16. Symptomatic Treatment
• Pain control : - Essential for quality patient care
- Ensures patient comfort , pulmonary toilet , sedation
- commonly used : Diclofenac , Acetamenophen ,
Tramadol ,
• Controlling Emesis – ondransetron mostly used
• Mobilization of patient
17. Management of metabolic complications
• Hypocalcemia : (500-2000)mg IV one time , rate not to exceed
(0.5-2) ml/min ( under continuous cardiac monitoring )
• Hyperglycemia : Insulin
• Hypoglycemia : glucose containing fluid infusion
• Diabetic Ketoacidosis
18. • Avoid prophylactic antibiotic doses – use ONLY for DEFINED INFECTIONS
( INFECTIVE NECROSIS or EXTRAPANCREATIC inf)
• Infection : Source : Gut flora
Organisms : Escherichia coli , Klebsiella pneumonia , Enterococcus sp.
INDICATIONS : 1. Infective necrosis
2. Sterile necrosis > 50%
3. Extrapancreatic infections
Prophylactic Antibiotic Therapy
• “….broad-spectrum antibiotics should be used early in the course of necrotizing
pancreatitis particularly in patients with signs of organ failure
or systemic sepsis.” – Maingot’s Abdominal Operations 12th Edition
19. The role of antibiotics in acute pancreatitis
•
Cholangitis, catheter-acquired infections, bacteremia, urinary tract
infections, pneumonia (strong recommendation, Level I evidence)
Routine use of prophylactic antibiotics in
patients with severe acute pancreatitis is not
recommended
(strong recommendation, Level II evidence).
20. Selection of antibiotics :
i. Either CT guided FNA for aspiration of pus, Gram stain and
culture should be done for determining apt antibiotic
or
ii. Emperical antibiotic therapy should be started after attaining proper specimen for
C/S
• Preferred antibiotics : 1. Carbapenem ( Imipenem+cilastatin)
2. Quinolones
3. Metronidazole
4. 3rd generation cephalosporines
• Secondary fungal infection (mainly Candida sp. ) - Fluconazole
Fig : FNA needle
21. Monitoring and reassessment
• Careful monitoring – Mild acute pancreatitis – general ward setting
- Severe acute pacreatitis – ICU setting
• Parameters in use : 1. Vitals
2. Laboratory Values : Hct, TLC , serum creatinine ,RBG ,
serum Na,K,Ca , Plateles , Bilirubin
3. Follow up of symptoms
4. Others : PaO2 , FiO2 , Arterial pH , Urine output , GCS
Scoring systems in use : APACHE II
Marshall ( for Organ Failure )
SOFA ( Mortality prediction in asso. With MODS )
22. These scores can be used as : * Individual scores for each organ ( for
Organ dysfunction )
* Sum of Scores on single ICU day
* Sum of worst scores during ICU
stay
* Better stratification of mortality risk
*Dynamic procedure
*NOT RESTRICTED BY ADMISSION VALUES
23. ERCP in acute pancreatitis
• Patients with acute pancreatitis and concurrent acute cholangitis should undergo
ERCP within 24 h of admission (strong recommendation, Level I evidence).
• ERCP is not needed in most patients with gallstone pancreatitis who lack laboratory
or clinical evidence of ongoing biliary obstruction (strong recommendation, Level II
evidence).
In the absence of cholangitis and / or jaundice, MRCP or endoscopic
ultrasound (EUS) rather than diagnostic ERCP should be used to screen
for choledocholithiasis if highly suspected.
• ERCP : Diagnostic and potentially therapeutic
24. When is early ERCP indicated
• Concomitant cholangitis (Evidence Level I)
• Significant persistent biliary obstruction (bilirubin > 5 mg/ dl) (Evidence A)
• ERCP in severe biliary pancreatitis without biliary sepsis or obstruction
(Evidence Level I)
25. When is early ERCP NOT indicated
• Mild pancreatitis of suspected or proven biliary etiology in the
absence of the biliary obstruction (Evidence Level I)
• DRAWBACK : Post ERCP Pancreatitis
Conditional recommendations of Pancreatic ducts/stents
Or Post-procedure Rectal NSAID Suppositories
26. Role of Surgery
• Surgical interventions addressed to : a. Aetiology
b. Complications
• Surgery in acute pancreatitis :
Emergency Elective Prevention of recurrence
• Infected Necrosis
• Haemorrhage
• Pancreatic abcess
• Fulminant
pancreatitis
• Abdominal
compartment syn.
• Colonic perforation
• Pseudocyst
• Pancreatic fistula
• cholecystectomy
27. • In stable patients with infected
necrosis
• In symptomatic patients with
infected necrosis:
• Surgical, radiologic, and / or
endoscopic drainage
Should be delayed preferably for
more than 4 weeks
To allow liquefication of the
contents and the development of a
fibrous wall around the necrosis
(walled-off necrosis) (Level II
evidence).
Minimally invasive methods of
necrosectomy are preferred to
open necrosectomy (Level II
evidence).
28. Surgery in Sterile Pancreatic Necrosis
Surgery in selected cases
• Massive pancreatic necrosis (>50%) with a deteriorating clinical
course (Evidence level I)
• Patients with progression of organ dysfunction (Level II)
• No signs of the improvement (Level II)
30. Mistakes in the management of acute pancreatitis and
how to avoid them
• Mistake 1 | Failing to adequately assess fluid status
• Mistake 2 | Delaying ERCP in patients with acute pancreatitis and cholangitis
• Mistake 3 | Delaying cholecystectomy in patients with biliary pancreatitis
• Mistake 4 | Early surgical or endoscopic intervention for acute necrotizing
pancreatitis
• Mistake 5 | Administering prophylactic antibiotics
• Mistake 6 | Recommending unnecessary bowel rest
• Mistake 7 | Performing routine cross-sectional imaging on admission