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MORBIDITY AND MORTALITY

Transcript: CASE PROGRESS... Thank You! CASE DISCUSSANT: DR. NICHT, KRYSTAL MD History of present illness PRESENTATION BY: BOTROS, MOUSA MD Medical comorbidities Surgeries Allergies Medical medications Notes about the circumstances when I met the patient. Family History Past medical history Background Past psychiatric history Social History MORBIDITY AND MORTALITY copy part from HPI note Female in her 40s.. MENTAL ILLNESS SUBSTANCE ABUSE MEDICAL PROBLEMS SUICIDE MENTAL STATUS EXAMINATION Admissions Outpatient treatment Past psychiatric medications ECT Trauma History 62 ECG bpm

Mortality and Morbidity

Transcript: What is MELD? T 98.2, HR 70-80, BP 120/70, RR 20, SaO2 low 80s HFNC 85% 50 L General: A+Ox3, comfortable PEERLA: EOMI, PEERLA CV: systolic murmur, JVD to the angle of the jaw Resp: bibasilar crackles Abd: soft NT ND no organomegaly 11/09: O2 sat dropped to 70-75%, recovered with increased PEEP. He continues on Flolan. IR => risks outweigh the benefits. 11/10: continuing diuresis. 11/11: O2 desat to 60s, failed recruitment maneuvre, started bagging him briefly, ETT chanmged for cuff leak. BP dropped after increased sedation and paralysis => PEA arrest 11/12: worsenign renal failure => CVVHD started, Worsening pressor requirement, and lactic acidosis o/n 11/13: made CMO, and passed away BW 1/03:Improved O2 saturations. MSSA in sputum at OSH, ID recs stop vanco/zosyn, start cefazolin. 1/04: Cards consult: Later worsening MS, and O2sat => intubated January 2016 Hala El Chami PGY 5 Gin et al., Am Heart Journal,1993 Autopsy Results NS 79 yo M, h/o Cor triatriatum, 4 V CABG, HFpEF who is transferred from OSH on 01/02 for worsening hypoxia. Admission at OSH from ID clinic with fever, cough, and weight loss on 12/30. Initially, saturation was 95%, he was given IV fluids and broad spectrum antibiotics. He then developed severe hypoxia after volume resuscitation with saturation in the 60s. Valid and reliable for risk stratification and survival projection after emergent TIPS Clinical Course Stable RR, O2 sat, looked ok, no need for emergent intubation. However, 3 "occasions" to intubate 1. CT 2. VT 3. increased WOB. Clinical course Effectiveness of TIPS in treating portal hypertension. Found that MELD score was an independent predictor of post-TIPS mortality. 68 year old man with hx CHF s/p ICD, ESRD on HD, Afib on Coumadin, CAD s/p recent LAD stent, COPD on 2L home O2, transferred from OSH for seizure, found to be septic ( infected HD cath vs. pna. Labs GD 68 LM 67 DP 63 DA 56 YK 82 SK 47 NS79 JJ 58 WB 68 Exam significant for labored breathing,accessory muscle use. Noticed to not move his right arm =>neuro consult for possible LMCA stroke Overnight, tried scoop mask, high flow, NRB, then BiPAP = Clinical Course JJ 58 yo M, h/o cirrhosis 2/2 HCV, HBV, esophageal and gastric varices, HIV, Parkinson's disease, bipolar disorder and dementia who initially presented to OSH with pancreatitis, complicated with massive hematemesis requiring large volume transfusion (reported 10u PRBC, 8u FFP, 12u platelets). An EGD at the OSH, showed both esophageal and gastric varices with a large amount of blood making visualization difficult and no overt bleeding source was identified. A Blackmore was placed, and he was sent to TMC for evaluation of TIPS procedure. Upon arrival, started on pressors. 11/05: inhaled flolan for worsneing hypoxia with some improvement, increased pressor requiirements => broad abx started 11/06: RHC revealed no step up. Oxygenation continuing to improve, plan to d/c flolan 11/07: Episode of desat, increased sedation and PEEP. Increased pressor requirements=>abx boradenet. TEE attempted but stopped due to UA bleeding. 11/08: TEE Negative for intracardiac shunt but possible intrapulmonary shunts, continued Flolan and diuresis. Discussion with family about further evaluation with angiography for possible embolization. prospectively developed and validated chronic liver disease severity scoring system that uses lab values (T-Bili, crea, INR) to predict three-month survival. Given its accuracy in predicting short-term survival among patients with cirrhosis, MELD was adopted by the United Network for Organ Sharing in 2002 for prioritization of patients awaiting transplantation. Mortality and Morbidity Physical Exam

Morbidity and Mortality

Transcript: How to Fight Obesity What is Added Sugar? Sugar increases ones likely hood of contracting and keeping certain diseases such as type 1&2 Diabetes 1 affects the pancreas's production of insulin and 2 affects how the body processes blood sugar, and Fatty Liver Disease , Osteoporosis, and many others. Another term for illness or close to death. What is Mortality? What is the recommended amount of added sugar? Morbidity and Mortality of Sugar in America There are many ways that the U.S. is currently using to fight obesity, one of which is to go on a 2,000 calorie protein diet, which may seem like it's very small, but it is actually a very good way to lose weight. As sen in this diagram. When something leads to someone being in the state of, or being subject to death. As little as possible, you can still eat it, but it is recommended that you eat as little as you can. But the recommended daily in take is about 5% of the calories you eat witch can range from 25 to 40 grams. What is Morbidity? Why is Added Sugar Morbid? 65% of people in America are Obese or considered overweight. That would be an estimate of 210,069,498. Americans also consume over 130lbs of sugar per person per year Added sugars are sugars and syrups that are added to foods or beverages when they are processed or prepared. How many people are obese?

MORBIDITY AND MORTALITY

Transcript: Left MCA infarct (2011) CAD s/p CABG X 3 (2004) Ischemic cardiomyopathy Hypertension Hyperlipidemia PAST MEDICAL HISTORY LABS CASE PRESENTATION VITAL SIGNS Nursing High patient to physician ratio High patient to pharmacist BY sOWMYA KORAPATI Aggrenox 25-200 mg BID Atorvastatin 80 mg daily Carvedilol 6.25 mg BID Lasix 40 mg daily Lisinopril 10 mg daily Potassium chloride 20 mEq daily No headache No fever, chills No palpitations, chest pain or shortness of breath PLACE PHYSICAL EXAM MORBIDITY AND MORTALITY ROOT CAUSE ANALYSIS SOCIAL HISTORY POLICY REVIEW OF SYSTEMS Day 1 - Keppra Day 2 - A Flutter with HR 60 - 85 Day 3 - Coumadin Day 4 - Discharge Lives at home with his wife 30 pack year smoking history quit 20 years ago No history of alcohol or substance abuse PEOPLE No apparent distress CVS - regular rhythm. S1 S2 heard. No murmurs, rubs or gallops Neuro - Alert and oriented to self and place. Expressive aphasia. Increased tone in right upper and lower extremity. Positive babinski on the right. Medication reconciliation Ordering Warfarin DAY OF DISCHARGE HOSPITAL COURSE DISCHARGED WITHOUT COUMADIN PROCEDURE BMP - with in normal limits CBC - witn in normal limits Glucose - 124 CT head - Large area of encephalomalacia in the left frontal parietal region. Chronic infarction in left cerebellum. Small vessel ischemic changes. CIPs - negative Carotid dopplers - less than 50% diameter stenosis in bilateral carotid arteries. Suspected seizure T - 97.3 BP - 148/85 Pulse - 71 RR - 18 O2 Sat - 98% RA REASON FOR ADMISSION Provider Physician - missed warfarin order - patient/family education Pharmacist - medication reconciliation did not include warfarin 14:39 - DISCHARGE INSTRUCTIONS 14:47 - PHARMACY MEDICATION RECONCILIATION NOTE 15:10 - PATIENT LEAVES 16:21 - PATIENT WAS DISCHARGED WITHOUT WARFARIN ORDER. MEDICATIONS

Morbidity and Mortality

Transcript: Decadron 40 mg daily Ergocalciferol 50,000 units weekly Norco 10/325 Q6H PRN Synthroid 75 mcg Disposition 9/14 - 9/22/2016: Patient admitted for grade 3 diarrhea. 9/17/2016: Colonoscopy - The entire colon had severe pan colitis. Tissue was ulcerated and friable. Biopsies were taken - mild architectural distortion with expansion of the lamina propria due to inflammation with minimal crypt distortion. There is diffuse lymphoplasmacytic inflammation admixed with neutrophils and eosinophils. Scattered cryptitis and crypt abscesses are present. The differential diagnosis includes drug reaction (immunotherapy), inflammatory bowel disease, and infectious colitis, correlate clinically. 9/19/2016: Started on hydrocortisone > tapering doses of prednisone. Since no improvement with prednisone, patient restarted on tapering doses of decadron ACGME Core Competencies Allergies Thoughts / Orders? Hospital presentation "lactic acid improved with IVF" Patient continues to complain of weakness and decreased appetite. Now he starts to complain of abdominal pain for the first time. Abdominal perforation highly suspected. Patient refused surgical options. He enrolled into hospice and passed away on day #3. Blood cultures grew 2/2 e coli Here are some extra assets : Surgical Assessment & Plan Father - cancer Mother - heart disease Sister - cancer OT: requires max assist for dressing/bathing/toileting SETUP for grooming and eating and MOD assist for transfers with RW. Pt demonstrated 3/5 for RUE strength and 2+/5 for L shoulder strength. Strong grasps bilaterally. Pt required max assist for supine<>sit and mod assist for sit<>stand. Constitutional: He is oriented x4. He appears malnourished and cachectic. No distress. Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate. Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Neck supple. No JVD present. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. He has no rales. He exhibits no tenderness. Abdominal: Soft. Bowel sounds are normal. He exhibits no distension and no mass. There is no tenderness. There is no rebound and no guarding. Musculoskeletal: He exhibits no edema or tenderness. Lymphadenopathy: He has no cervical adenopathy. Neurological: He is alert and oriented to person, place, and time. He is not disoriented. He displays weakness. He displays no atrophy and no tremor. No cranial nerve deficit or sensory deficit. He exhibits normal muscle tone. Coordination normal. 3/5 proximal LE strength bil 4/5 distal extensor and flexor strength bilaterally. Skin: Skin is warm and dry. No rash noted. He is not diaphoretic. No erythema. No pallor. Psychiatric: Mood, memory, affect and judgment normal. ROS Exam none Nursing documentation: pt assisted to bedside commode for BM; only dark blood noted in commode with 4 quarter sized clots. Amber urine noted as well. Patient assisted back to bed. DR notified. VSS. HGB stable. GI consulted for GI bleed PET SCAN Past history Medical Obs day #1 FEEL FREE TO COPY & PASTE THEM! Jeff Valice PGY-3 12/19/2016 former PPD smoker x 12 years, quit 1980 denies alcohol denies illicit drugs Additional information PT: mod assist for bed mobility, transfer and gait training. Family CABG in 2003 Tonsillectomy 2007 with chemo, radiation and PEG Medications Mild asymmetric focal uptake is seen in the lateral aspect of the right globe with maximum SUV of 6.4. There are numerous small and large hypodense lesions seen throughout the liver with intense uptake. Maximum SUV in right hepatic lobe measures 15.1. Maximum SUV in caudate lobe lesion measures 14.5. Review of skeletal structures demonstrates lytic lesions in the left iliac crest with maximum SUV of 23.7 as well as in the left acetabulum with maximum SUV of 42. BP 113/52 HR82 T 36.6 RR 20, 97% RA, BMI 20 Went for routine eye exam 4 months prior, sent to retinal specialist who diagnosed him with choroid malignant melanoma. Constitutional: Positive for malaise/fatigue and weight loss. Negative for chills, diaphoresis and fever. HENT: Negative for congestion and sore throat. Eyes: Negative for blurred vision and double vision. Respiratory: Negative for cough, shortness of breath and wheezing. Cardiovascular: Positive for leg swelling. Negative for chest pain, palpitations, orthopnea, claudication and PND. Gastrointestinal: Negative for abdominal pain, blood in stool, constipation, diarrhea, heartburn, melena, nausea and vomiting. Genitourinary: Positive for hematuria. Negative for dysuria and urgency. Musculoskeletal: Negative for back pain, joint pain, myalgias and neck pain. Skin:

Morbidity and Mortality

Transcript: Fever Elevated temperatures can increase the degree of ischemic injury. Etiologies include infection, neuronal injury, SIRS Studies have demonstrated increased morbidity and mortality in patients with sustained temperature elevation. Treat temperture > 38.5'C Acetaminophen or a cooling blanket best options. Treatment should be started within 6 hours of symptom onset A Prospective Multicenter Study to Evaluate the Feasibility and Safety of Aggressive Antihypertensive Treatment in Patients with Acute Intracerebral Hemorrhage Journal of Intensive Care Medicine Etiologies Lab and disposition Morbidity and Mortality 20151217 presenter 嘉義醫院家醫科:張枝清醫師 Essential Hypertension Eclampsia Sympathomimetics Cocaine Amphetamines Phenylpropanolamine ICH surgical indications Cerebellar hemorrhage > 3 cm who are deteriorating or with brain stem compression and hydrocephalus from ventricular obstruction Vascular malformation if lesion is surgically accessible and patient has chance for good outcome Young patients with a moderate or large lobar hemorrhage who are clinically deteriorating ED Administered(Rx.) Seizure Neuronal injury may lead to seizures Nonconvulsive seizures may contribute to coma in up to 10% of neurocritical patients Consider prophylactic antiepileptic therapy in setting of ICH Lobar hemorrhage-35% seizure rate Fosphenytoin or phenytoin Non-surgical ICH P'ts Small Hemorrhages (10cm3) Minimal neurological deficits GCS < 4 (excluding cerebellar hemorrhage with brain stem compression) Endotracheal Intubation Lower blood pressure to decrease risk of ongoing bleeding from ruptured small arteries Overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and worsen brain injury Especially true with elevated ICP Amyloid Trauma Vascular malformationAVM, cavernoushemangiomas Aneurysm Tumor Coagulopathy Vasculitis Stroke July 2015 Paralytics Recommended in order to prevent increasing intrathoracic and venous pressures associated with coughing, suctioning, and bucking on ETT, all of which may cause ICP spikes ICP spikes associated with poorer outcome, especially in setting of elevated ICP Hypertensive ICH Paralytics-Pancuronium 7 mg BP management-Nipride Steroids-Decadron 10 mgs U.A. Color Yellow Sugar - Occult Blood 4+ Pro. 3+ Leucocytes 1+ RBC numerous WBC 5-10 Bacteria 2+ Appearance Cloudy PT 10.3 sec INR 1.00 APTT 26 sec WBC 13.18 k RBC 4.67 M Hb 15.5 g/dl Hct 42.3 Platelet 90k MCV 90.6 fL Diff Segmented 87.6% Blood ammonia 77 12～66μg/dL Blood gas analysis mpH 7.44 mPCO2 33mmHg mPO2 77 mmHg cHCO3act 22 cBE(vv) -1.8 mmol/L cO2SAT 95 % Creatinine 1.1 UREA-N(blood) 11.9mg/dl Glucose 178mg/dl Na 144 K (Potassium) 3.8 mmol/L S-GOT 96 S-GPT 56 CPK 90 U/L Albumin 3.51 g/dl EKG NSR (Normal Sinus Rhythm) After B/C x ii ,supercef 1Gm iv he's Admitted to ICU with impressions of 1.Sepsis(UTI with hematuria) 2.UGIB 3.Hepatic encephalopathy 4.Ac. respiratory failure ICH Types Epidural Subdural Subarachnoid Intraparencymal Intraventricular Cerebellar Basal ganglia (50%) Contralateral hemiparesis, sensory loss, conjugate gaze Lobar regions (20-50%) Contralateral hemiparesis or sensory loss, aphasia, neglect, or confusion Thalamus (10-15%) Contralateral hemiparesis, sensory loss, gaze paresis Pons (5-12%) Quadriparesis, facial weakness, decreased level consciousness Cerebellum (1-5%) Ataxia, miosis, gaze paresis Osmotherapy osmotherapy-Mannitol Reduces cerebral edema by decreasing cerebral fluid volume Rebound effect-use less than 5 days 20% solution 0.5-1.0 mg/kg maintain serum osmolarity 310-320 mOsm/L BP management Labetalol 20 mg IV, followed by 40 80 mg IV q10 min Titrate to BP or max 300 mgs admin. Nipride 0.5-1.0 mics/kg/min Theoretically can increase cerebral blood flow and thereby intracranial pressure 52 year-old male found moaning on bed by neighbor then sent by 119 to our ER. Vital signs BT:38.6BP 224/137 HR108 RR:30 Ox:93% ER Findings GCS:E2V2M4 coffee-ground vomitus Past Hx:Liver cirrhosis (HCV) related case report Thank You For your comment COMA? Brain CT Conscious loss? Sepsis? Intubation-not required, but airway protection and adequate ventilation are necessary Rely on clinical suspicion, not GCS Hyperventilation decreases ICP pCO2 should be kept around 30-35 Beneficial effect of sustained hyperventilation is not proven RSI Lidocaine 100 mgs Etomadate 20 mgs SuccinylCholine 100 mgs Mannitol 150 ccs Elevate Head of Bed Hyperventilation to pCO25-30 Avoid hypotension If systolic BP drops to less than 90 mmHg, consider judicious fluid boluses and/or start pressors

MORBIDITY AND MORTALITY

Transcript: Dona Remedios Trinidad Romualdez Medical Foundation Inc. College of Biomedical Sciences Bachelor in Medical laboratory Science Calanipawan Road, Tacloban City, Leyte Philippines Top 10 Leading Causes of Morbidity & Mortality on Adults Morbidity and Mortality Terms 1 2 3 4 Morbidity is the state of being symptomatic or unhealthy for a disease or condition.It is usually represented or estimated using prevalence or incidence. Mortality is related to the number of deaths caused by the health event under investigation. Morbidity & Mortality Top 10 Leading Causes of Morbidity and Mortality on Adults Morbidity Bronchitis is an inflammation of the bronchial tubes, the airways that carry air to your lungs. It causes a cough that often brings up mucus. It can also cause shortness of breath, wheezing, a low fever, and chest tightness. Influenza is a viral infection that attacks your respiratory system — your nose, throat and lungs. Influenza is commonly called the flu, but it's not the same as stomach "flu" viruses that cause diarrhea and vomiting. For most people, influenza resolves on its own. A urinary tract infection (UTI) is an infection in any part of your urinary system — your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the urethra. Diarrhea is loose, watery stools (bowel movements). You have diarrhea if you have loose stools three or more times in one day. Acute diarrhea is diarrhea that lasts a short time. It is a common problem. It usually lasts about one or two days, but it may last longer. Then it goes away on its own. *Active TB is an illness in which the TB bacteria are rapidly multiplying and invading different organs of the body. *Miliary TB is a rare form of active disease that occurs when TB bacteria find their way into the bloodstream. In this form, the bacteria quickly spread all over the body in tiny nodules and affect multiple organs at once. *Latent TB Infection, many of those who are infected with TB do not develop overt disease. They have no symptoms and their chest x-ray may be normal. Dengue fever is a mosquito-borne disease that occurs in tropical and subtropical areas of the world. Mild dengue fever causes a high fever, rash, and muscle and joint pain. A severe form of dengue fever, also called dengue hemorrhagic fever, can cause severe bleeding, a sudden drop in blood pressure (shock) and death. The bacterium Mycobacterium tuberculosis causes tuberculosis (TB), a contagious, airborne infection that destroys body tissue. Pulmonary TB occurs when M. tuberculosis primarily attacks the lungs. However, it can spread from there to other organs. Pulmonary TB is curable with an early diagnosis and antibiotic treatment. Acute respiratory infection is a serious infection that prevents normal breathing function. It usually begins as a viral infection in the nose, trachea (windpipe), or lungs. If the infection is not treated, it can spread to the entire respiratory system. Acute respiratory infection prevents the body from getting oxygen and can result in death. Pneumonia is an infection of the lungs with a range of possible causes. It can be a serious and life-threatening disease. It normally starts with a bacterial, viral, or fungal infection. The lungs become inflamed, and the tiny air sacs, or alveoli, inside the lungs fill up with fluid. Hypertension High blood pressure is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease. You can have high blood pressure (hypertension) for years without any symptoms. Even without symptoms, damage to blood vessels and your heart continues and can be detected. Uncontrolled high blood pressure increases your risk of serious health problems, including heart attack and stroke. Mortality More deaths in males than females In 2017, the number of deaths in males (332,517) was higher than deaths in females (246,720). This translates to a sex ratio of 135, which means that there are 135 male deaths for every 100 female deaths Most deaths due to ischaemic heart diseases Figure 8 shows the ten leading causes of death in 2017. It can be seen that among the total deaths, ischaemic heart diseases were the leading causes of death with 84,120 or 14.5 percent. Second were neoplasms which are commonly known as “cancer” with 64,125 or 11.1 percent, followed by cerebrovascular diseases with 59,774 or 10.3 percent Ischaemic heart disease. It's the term given to heart problems caused by narrowed heart arteries. When arteries are narrowed, less blood and oxygen reaches the heart muscle. Ischemia is a condition in which the blood flow (and thus oxygen) is restricted or reduced in a part of the body. Cardiac ischemia is the name for decreased blood flow and oxygen to the heart muscle. CLRD actually comprises three major diseases, i.e., chronic bronchitis, emphysema, and asthma, that are all characterized by

Morbidity And Mortality

Transcript: Imaging Studies: CXr: no acute cardiopulmonary pathology Head CT: NAD Labs: CBC, CMP, BNP, and Coagulation Panel Unremarkable Troponin is 1.08 Labs/Imaging Studies: Cholecystectomy Past Medical History: Dispost Physical Exam CHF, HTN, A-fib CVA with a residual loss of vision in R eye Morbidity And Mortality The patient is a eighty-nine year old female who comes in today for evaluation of right foot numbness. Approximately 1.5 hours ago, the patient complained to her daughter of cramping in her right lower extremity. Then she started complaining of numbness in her right foot. Her daughter was concerned and brought the patient in for further evaluation and treatment. The patient's daughter denies that she has fallen or received any trauma recently. The patient denies any headaches, auditory or visual changes, coughing, chest pain, change in her baseline shortness of breath, abdominal pain, vomiting, dysuria, change frequency, and has no further complaints at this time. Constituation: pleasantly demented HENT: NC, AT Eyes: EOM intact Lungs: tachypneic with a slight wheeze Abd: Soft, NT, ND Extremities: No lower extremity edema, good cap refill x 4 Neuro: at baseline mental status sensation to light touch intact patella reflexes are +2 bilaterally NKDA By Puneet Gupta, MD CMU Emergency Medicine THE CASE!!! MS Exam: The patient is 5/5 to the following movements bilaterally Foot dorsiflexion and plantar flexion Extensor hallucis longus extension Knee flexion and extension Hip flexion, extension, internal and external rotation Finger grip Finger extension Finger opposition Wrist extension and flexion Bicep flexion Tricep extension Shoulder abduction, abduction, internal and external rotation Past Surgical History: Physical Exam ICU.... Allergies:

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