CASE PRESENTATION

Dr. Raihana Al-Anqoudi

OUTLINE Saying HELLO.

The case.

The topic.(Management & Disposition)

Take home messages.

THE CASE J.M 48 y old man. R.H casuality @ 20:30. C/O : upper abd pain and vomiting. BP=94/67 PR=120/mnt T=37

WHAT DO U WANT TO KNOW / DO?

Primary Survey 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

HISTORY

S : since morning , upper abd pain, radiating to back and retrosternally, associated with vomiting, no diarrhea, no fever.

A : no allergies. M : not on any medications. Smoker

and ethanol consumer ?? Iv drug abuser.

P : no past medical or surgical history. L : not recalling,, vomits whatever

eaten.

SECONDARY SURVEY

Generally ; dehydrated, no visible veins, has tattoo , restless, poor hygiene with smell of alcohol from his mouth.

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.

48yr old male no medical problem

smoker, alcoholic , drug addict upper abd tenderness

hypovolemic ECG and troponin not suggestive

of ischemiaWHAT IS NEXT

WHAT IS IN UR MIND

ACTIONS TAKEN

Labs for CBC, UE, LFT, TROPONIN, COAGULATION AND AMYLASE.

Received IVF 500ml, metoclopromid , ranitidine and tramal .

Ordered for CXR.

Labs Results Troponin negative.

Coagulation within normal

Amylase within normal

LFT : bilirubin 72 ALP=173 ALT=68 ALB=27

Labs Results

CBC : Hb=14.7 PLT=170 WBC=23.8 with N=19.7

UE : Na= 134 K= 4.4 CO2= 21 Cl=100 Urea= 14.6 Creat= 160

Then what happened to J.M the treating physicians decided he is fit

for discharge, so disposed home. His relative asleep at home, so when

contacted said will come in morning to pick him up.

Kept in day ward, when over taken to waiting area ,comes back to be saying he is SICK.

In morning, security and PRO called to do something as refused to leave the bed.

When relative finally arrived, when reached the car, noticed that he is really sick and brought him back.

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.

Finally another set of vitals which showed: PR=140/mnt

BP=114/73 RR= 26/mnt saturation= 91%

Kept in monitor bed. IV line put by anesthetist, given IVF.moxifloxacillin,tazocin and cotrimoxazole Immediate medical review. Admitted to HD, then shifted to ICU. Went to : ARDS pneumothorax surgical emphysema from neck to scrot.

PASSED AWAY.

Pneumonia(management)

Possibility of communicable disease suggest early isolation.

Timely administration of antimicrobials associated with improved outcome.

Prevalence of DRSA is increasing. CA-MRSA is a cause of rapidly

progressive pneumonia with sepsis

Pneumonia(management)

Antimicrobial agent should be tailored according to :

Simple CAP. DRSP. MRSA. P. aerugensa.

Pneumonia (Disposition)

Variability in physician admission decisions.

No firm guidelines but scoring system assist with hospitalization decision.

One commonly used is the prospectively validated predictive rule of mortality

The pneumonia patient outcomes Research Team Study (pneumonia

severity index PSI

Pneumonia severity index PSI

Age Male No. years of age  Female No. years of age −10 Nursing home resident 10Comorbid illness Neoplastic disease 30  Liver disease 20  Congestive heart failure 10

 Cerebrovascular disease 10  Renal disease 10Physical examination finding Altered mental status 20  Respiratory rate ≥ 30 20   Systolic blood pressure ≤90 mm Hg 20  Temperature < 35° C or > 40° C 15   Pulse ≥ 125 beats/min 10Laboratory or radiographic finding Arterial pH < 7.35 30  Blood urea nitrogen >30 mg/dL 20  Sodium <130 mEq/L 20  Glucose > 250 mg/dL 10  Hematocrit < 30% 10  Arterial PO2< 60 mm Hg 10

  Pleural effusion 10

PSI

Hospitalizations is recommended with a score greater than 91.

A brief admission or observation for 71-90

It is not modeled for to predict acute life threatening events.

Clinical judgment supersede strict interpretation of PSI.

Revealed significantly lower admissions and cost.

CURB-65 rule

Another tool, easier to use. Confusion.. Ureamia (urea > 20mg/dl) RR > 30 BP , systolic < 90,, diastolic > 60 Age 65 or greater.

CURB-65

Risk of 30 day mortality: 0 factor 0.7% (0-1 can be

outpatient) 2 factors 9.2% (with 2 should admit) 5 factors 57% (3 or more consider

ICU)

No randomized trials compared PSI vs CURB-65.

TAKE HOME SMS