11. CVS; S1 S2; normal, ECG; sinus rythem , bed side troponin is negative.
12.
13. ACTIONS TAKEN Labs for CBC, UE, LFT, TROPONIN, COAGULATION AND AMYLASE. Received IVF 500ml, metoclopromid , ranitidine and tramal . Ordered for CXR.
14.
15. Labs Results Troponin negative. Coagulation within normal Amylase within normal LFT : bilirubin 72 ALP=173 ALT=68 ALB=27
16.
17. 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.
18. 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%
25. 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
26. Pneumonia severity index PSI AgeโMale No. years of age โ Female No. years of age โ10 Nursing home resident 10 Comorbid illnessโNeoplastic disease 30 โLiver disease 20 โCongestive heart failure 10 โCerebrovascular disease 10 โ Renal disease 10 Physical examination finding Altered mental status 20 โRespiratory rate โฅ 30 20 โ Systolic blood pressure โค90ย mmย Hg 20 โ Temperature < 35ยฐโC or > 40ยฐโC 15 โ Pulse โฅ 125 beats/min 10 Laboratory or radiographic finding Arterial pH < 7.35 30 โBlood urea nitrogen >30ย mg/dL 20 โ Sodium <130ย mEq/L 20 โGlucose > 250ย mg/dL 10 โ Hematocrit < 30% 10 โ Arterial Po2< 60ย mmย Hg 10 โ Pleural effusion 10
27. 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.
28. CURB-65 rule Another tool, easier to use. Confusion.. Ureamia (urea > 20mg/dl) RR > 30 BP , systolic < 90,, diastolic > 60 Age 65 or greater.
29. 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.
