welcome back to the high-yield video question Bank in this video series I'm trying to help you train your brain to recognize high yield patterns and think like somebody who's trying to solve a puzzle so that when you take us Emily or comlex your brain has already recognized high yield patterns and knows what to expect in order to get the question correct today's question says a 66 year old female with no past medical history presents to the emergency department complaining of a cough productive of a yellow-green sputum for the past 36 hours she's brought in by family members who state that she has been otherwise her normal self her blood pressure is 99 over 70 heart rate 92 respiratory rate 22 a chest x-ray is consistent with pneumonia the following set of labs are obtained bu n is 18 creatinine is 0.44 sodium is 140 and potassium is 4.0 which of the following levels of care is most appropriate at this time a outpatient follow-up B emergency pulmonology consult in the emergency department C hold in the II D for observation D inpatient general medical floor or II intensive care unit pause the video if you'd like to think about this and if you're ready I'm going to give you the answer and go into the explanation so the correct answer here is a outpatient follow-up and if you're looking at this question of thinking to yourself huh this kind of seems like a clinical question is this really fair game for step one the answer is yes and with that said it's a perfect segue into the concept that you need to be familiar with which is called curb 65 so curb 65 is a point scale that we use to determine what needs to happen to folks who come in and are found to have pneumonia basically it is a point scale with certain categories and the points are added up and based on how many total points patient has you can figure out are they safe to be discharged should they get admitted to the hospital or should they get admitted to the intensive care unit curb 65 stands for confusion bu n respiratory rate blood pressure and age greater than 65 now when you look at curb 65 you have to look at the scale and ask yourself some questions so for confusion it's a simple yes/no question does the patient have confusion or do they not for bu n the question is is the BU n 20 or higher for respiratory rate the question is is the respiratory rate 30 or higher for blood pressure the question is is the blood pressure less than 90 over 60 and for age it's a yes/no question are they older than 65 now for each of these categories you can get one point assigned so if they have confusion they get a point if they're bu n is 20 or higher they get a point if the respiratory rate is 30 or higher they get a point if their blood pressure is less than 90 over 60 they get a point and if they are age greater than 65 they get a point and of course because there's five components of curb 65 the most amount of points that any patient could score on this scale is five so what you do is you look at a question and you calculate the curb 65 score for pneumonia and once you have that score you can then determine what you need to do with the patient and the WIPP the way that you should think about this is if the score is zero or one they can be discharged and go into the outpatient setting to follow up with their primary care physician or just treat themselves at home if their scoring - they get admitted to the hospital generally on the general medical floor and if their scoring three or higher they actually go right to the intensive care unit because it's a really severe case of pneumonia now how do you remember the interpretation of the curb 65 score the way that I memorize this is that for zero to one I replace the O and the T and outpatient with zero and one so that reminds me that if you're scoring zero one you know zero or one you go outpatient because the zero is what the word starts with and I replace the T with the one so 0 or 1 is outpatient and then three or more is the ICU because there are three letters in ICU so if you score three or more on curb 65 you go to the level of care that has three letters which is the ICU and then by the process of elimination I just remember that the one in the middle must be the one that I haven't talked about yet which is inpatient so zero one you go outpatient to inpatient three or more ICU because there's three letters in ICU so this is how you use curb 65 and again this is only gonna come up in questions where they give you a patient with pneumonia or they describe somebody with pneumonia and they're asking you should they be discharged should they go general medical floor should they go intensive care unit and again I know that this is a very clinically oriented question that you might expect on step two level two step three level three but it's really showing up more and more so you should commit it to memory now you'll also impress your attendings if you know the curb 65 score so now that you understand how curb 65 works let's go back to the practice question and work through it using curb 65 so here's the practice question exactly as it was written before and I put curb 65 on the bottom left-hand side of this screen to just help you kind of solve through this question so the first thing that we notice is the patient's age right the question tells us that the patient is a 66 year old female so because she's 66 they're for age greater than 65 she scores a point for the age category now let's go through I guess we'll just go straight down confusion B UN respiratory rate blood pressure and look at if there's gonna be points scored so for confusion the question told you that she's brought in by family members but say that she's been otherwise her normal self so what you can infer from that sentence is that there's no altered Mental Status and therefore the patient does not score a point for the presence of confusion what about B UN well the question tells you in the lab section that B UN was 18 and because you only score the point if bu n is 20 or more there's no point scored for bu n for respiratory rate the question tells you that the respiratory rate is 22 and while that's certainly an elevated respiratory rate in order to score a point on curb 65 the respiratory rate would have to be 30 or higher therefore the patient and this question does not score a point for respiratory rate and then lastly we've got blood pressure the question tells you that her blood pressure is 99 over 70 and in order to score a point on curb 65 your blood pressure has to be less than 90 over 60 so this does not meet that criteria and therefore the patient does not score a point for blood pressure so when it's all said and done if we apply curb 65 to this practice question the patient is only scoring one point and it's by virtue of her age so now the question was what happens outpatient inpatient or ICU and if we put our interpretation of curb 65 back on this slide we can recall that zero or one points is outpatient two points is inpatient and three or more points is the level of care with three letters so the ICU in this question she only scores one point because of her age and therefore the correct answer is to discharge the patient to take care of herself at home or do outpatient follow-up so the high yield bottom line of this practice question is that curb 65 is used to determine what should happen to a patient who comes into the edie with pneumonia do they get discharged with an antibiotic to take care of themselves at home do they get admitted to the general medical floor or do they get admitted straight to the intensive care unit confusion if yes one point B UN if greater then twenty one point respiratory rate if greater than thirty one point blood pressure if less than 90 over 60 one point and age if greater than 65 one point zero to one outpatient to inpatient three or more the level of care with three letters ICU