Abstracting Questions: 1. What items of Review of Systems (ROS) were documented? 2. Under what report heading(s) would the ROS be found? 3. Was the patient the driver or passenger in the motor vehicle?
Added by Jennifer E.
Step 1
Step 1: Identify the specific items documented in the Review of Systems (ROS) by examining the medical record or report for any listed symptoms or findings related to different body systems. Show more…
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A 45-year-old man was admitted to the hospital with complaints of extreme fatigue and back pain. The patient was diagnosed with hypertension 8 months ago and was prescribed methyldopa. The patient has never been transfused. Admission testing results are as follows: Hemoglobin: 7.5 g/dL Hematocrit: 22% Total bilirubin: 6.8 mg/dL The attending physician ordered four units of packed red blood cells for transfusion as soon as possible. Records indicate that 3 years ago the patient was transfused with four units of red blood cells following an automobile accident. No serological problems were noted at that time. 5. R's DAT result is interpreted as follows: A. Positive B. Negative C. Positive IgG only D. Positive IgG and C3d E. Positive C3d only 6. Given the patient history and serology results, the next test you would perform would be a(n): A. Elution B. Antibody identification panel C. Autoadsorption D. Warm saline wash technique 7. Which of the following describes the mechanism by which the autoantibody was produced in this case? A. Drug adsorption B. Immune complex C. Membrane modification D. Drug-induced autoimmune hemolytic anemia
Adi S.
A Case Study in Blood An ambulance arrives at the scene of an automobile accident, having been summoned by an in-vehicle security system. What the emergency personnel find is like a scene from a horror film. Maggie Silvers, the apparent driver of the car, is sitting, slumped next to the vehicle, with blood covering her shirt and hands. Her car has clearly hit a tree: a branch is sticking into the driver's window, and the airbag has been deployed. Maggie looks dazed, and as the paramedics approach she says with a mixture of panic and relief, "There's blood everywhere!" Maggie is only semi-lucid as she babbles on about pushing out the broken glass in her car window. Maggie, a 48-year-old woman, is, indeed, bleeding profusely from multiple left-arm cuts and an especially deep laceration on her left upper arm. The paramedics stop the bleeding and move her quickly to the ambulance, after noting no other apparent injury. Her systolic blood pressure is 80 mm Hg (low), and her diastolic is not audible (too low to hear). Her heart rate is 122 bpm (very rapid), and her skin is pale and clammy, indicating peripheral vasoconstriction (narrowing of her blood vessels, particularly in the skin) and circulatory shock-like signs. On the way to the hospital, a paramedic begins transfusing normal saline solution (NSS; water with some NaCl, similar to body fluids, given directly into her vein). A fast hematocrit (HCT) test upon Maggie's arrival to the emergency department (ED) indicates that her HCT is low, but normal. Several vials of Maggie's blood are also sent to the lab for blood tests and typing. Two liters of NSS are transfused over the next hour while the ED physician sutures her deepest, left-upper-arm laceration. Despite no further bleeding since the paramedics treated her at the scene, Maggie's next HCT, tested one hour after the original HCT, drops to below normal. Aside from her present health problem, Maggie is otherwise healthy. She is admitted to the hospital for overnight observation. Case Questions: 5. Why might a physician be reluctant to order a blood transfusion for Maggie, or for any patient for that matter, unless absolutely necessary?
An ambulance arrives at the scene of an automobile accident, having been summoned by an in-vehicle security system. What the emergency personnel find is like a scene from a horror film. Maggie Silvers, the apparent driver of the car, is sitting, slumped next to the vehicle, with blood covering her shirt and hands. Her car has clearly hit a tree: a branch is sticking into the driver's window, and the airbag has been deployed. Maggie looks dazed, and as the paramedics approach she says with a mixture of panic and relief, "There's blood everywhere!" Maggie is only semi-lucid as she babbles on about pushing out the broken glass in her car window. Maggie, a 48-year-old woman, is indeed bleeding profusely from multiple left-arm cuts and an especially deep laceration on her left upper arm. The paramedics stop the bleeding and move her quickly to the ambulance, after noting no other apparent injury. Her systolic blood pressure is 80 mm Hg (low), and her diastolic is not audible (too low to hear). Her heart rate is 122 bpm (very rapid), and her skin is pale and clammy, indicating peripheral vasoconstriction (narrowing of her blood vessels, particularly in the skin) and circulatory shock-like signs. On the way to the hospital, a paramedic begins transfusing normal saline solution (NSS; water with some NaCl, similar to body fluids, given directly into her vein). A fast hematocrit (HCT) test upon Maggie's arrival to the emergency department (ED) indicates that her HCT is low, but normal. Several vials of Maggie's blood are also sent to the lab for blood tests and typing. Two liters of NSS are transfused over the next hour while the ED physician sutures her deepest, left-upper-arm laceration. Despite no further bleeding since the paramedics treated her at the scene, Maggie's next HCT, tested one hour after the original HCT, drops to below normal. Aside from her present health problem, Maggie is otherwise healthy. She is admitted to the hospital for overnight observation.
Sri K.
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