Sandbox/22: Difference between revisions

Revision as of 15:12, 20 March 2014

Examine the patient

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-===General Approach===
 {{familytree/start}}
-{{familytree | | | A01 | | A01=<div style="float: left; text-align: left;"> '''Characterize the symptoms:''' <br>
+{{familytree | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient'''<br>
-❑ '''Low red blood cell count or low hemoglobin level'''<br>
+❑ <br>
-:❑ Difficulty concentrating <br>
+❑ <br>
-:❑ [[Insomnia|Difficulty sleeping]] <br>
+❑ <br>
-:❑ [[Dizziness]]<br>
+❑ <br>
-:❑ [[Fatigue|Easy fatigability]]<br>
+❑ <br>
-:❑ [[Headache]] <br>
+❑ <br>
-:❑ [[Pallor|Pale skin]]<br>
+❑ <br>
-:❑ [[Tachycardia|Rapid heart beat]]<br>
+❑ <br>
-:❑ [[Shortness of breath]] <br>
+❑ <br>
-❑ '''Low white blood cell count'''<br>
+❑ <br>
-:❑ Abnormal [[bleeding]] <br>
+❑ <br>
-:❑ [[Fever]]
+❑ <br>
-:❑ [[Irritability]] <br>
+❑ <br>
-:❑ [[Neurasthenia]]<br>
+❑ <br>
-:❑ Recurrent infections - [[Aphthous ulcer|canker sores]], [[gingivitis]], [[periodontitis]]
+❑ <br>
-❑ '''Low platelet count''' <br>
+❑ <br>
-:❑ Blood in urine or stool <br>
+❑ <br>
-:❑ Easy or excessive bruising<br>
+❑ <br>
-:❑ [[Menorrhagia|Heavy menstrual flow]] <br>
+❑ <br>
-:❑ Prolonged bleeding during [[surgery]]<br>or after [[Extraction (dental)|tooth extraction]]<br>
+❑ <br>
-:❑ Prolonged bleeding from cuts</div>}}
+❑ <br>
-{{familytree | | | |!| | |}}
+❑ <br>
-{{familytree | | | B01 | | B01=<div style="float: left; text-align: left;"> '''Obtain a detailed history:''' <br>
+❑ <br>
-❑ Review medical records<br>
+❑ <br>
-❑ Past medical history <br>
+❑ <br>
-:❑ Previous [[blood transfusion]] <br>
+❑ <br>
-:❑ Cardiovascular disease <br>
+❑ <br>
-::❑ [[Hypertension]] <br>
+❑ <br>
-::❑ [[Arryhthmias]] <br>
+❑ <br>
-:❑ [[Trauma]] <br>
+❑ <br>
-:❑ Previous [[Surgery]] <br>
+❑ <br>
-:❑ [[Infection]]s e.g., [[HIV]] <br>
+❑ <br>
-:❑ [[Malignancy]] <br>
+❑ <br>
-:❑ [[Chronic kidney disease]]<br>
+❑ <br>
-:❑ [[Lung disease|Chronic lung disease]]<br>
+❑ <br>
-:❑ Family history of bleeding<br>
+❑ <br>
-❑ [[Medications]] - [[anticoagulants]], [[thrombolytics]]</div>}}
+❑ <br>
-{{familytree | | | |!| | |}}
+❑ <br>
-{{familytree | | | W01 | | |W01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Examine the patient:'''<br>
+❑ <br>
-❑ Vital signs:
+❑ <br>
-::❑ [[Blood pressure]]: ↓
+❑ <br>
-::❑ [[Pulse rate]]: ↑ or ↓
+❑ <br>
-::❑ [[Respiratory rate]]:  ↑ or ↓
+❑ <br>
-::❑ [[Oxygen saturation]]: ↓ (<90%)
+❑ <br>
-::❑ [[Temperature]]: ↑ or ↓ in sepsis<br>
+❑ <br>
-:❑ Skin:
+❑ <br>
-::❑ [[Pallor]]
+❑ <br>
-::❑ [[Jaundice]]
+❑ <br>
-::❑ [[Petechiae]], [[ecchymosis]]
+❑ <br>
-::❑ [[Bleeding|Active bleeding]]
+❑ <br>
-:❑ Central nervous system:
+❑ <br>
-::❑ [[Altered mental status|Altered sensorium]]
+❑ <br>
-::❑ Personality changes
+❑ <br>
-:❑ Lungs:
+❑ <br>
-::❑
+❑ <br>
-:❑ Abdomen:
+❑ <br>
-::❑ [[Abdominal distension]]
+❑ <br>
-::❑ [[Abdominal tenderness]]
+❑ <br>
- </div>}}
+❑ <br>
-{{familytree | | | |!| | |}}
+❑ <br>
-{{familytree | | | C01 | | |C01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order laboratory tests (Routine):'''<br>
+❑ <br>
-----
+❑ <br>
-❑ [[Complete blood count|CBC]]  <br>
+❑ <br>
-❑ [[Electrolytes|Serum electrolytes]]<br>
+❑ <br>
-❑ [[BUN]], [[creatinine]]<br>
+❑ <br>
-❑ [[Prothrombin time|PT]]/[[Partial thromboplastin time|PTT]]<br>
+❑ <br>
-❑ Type and screen (when transfusion is unlikely)<br>
+❑ <br>
-❑ Type and [[Cross-matching|crossmatch]] (if transfusion is certain)<br>
+❑ <br>
-:❑ [[ABO blood group system#ABO Antigens|ABO antigens]] and [[antibodies]]<br>
+❑ <br>
-:❑ [[Rhesus blood group system|Rhesus (D) antigen]]<br>
+❑ <br>
-:❑ Antibodies to [[red cell]] [[antigens]] (antibody screen)<br>
+❑ <br>
-'''Note''' - Send fresh samples whenever a second transfusion is required
+❑ <br>
-----
+❑ <br>
-'''Other additional laboratory tests to determine etiology:'''<br>
+❑ <br>
-❑   <br>
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-❑ <br>
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-❑ </div>}}
-{{familytree | | | |!| | |}}
-{{familytree | | | D01 | | |D01=<div style="float: left; text-align: left;">'''Pre-transfusion preparation:''' <br>
-'''4 R's''' - right '''Blood''', right '''Patient''', right '''Time''', right '''Place'''<br>
-❑  Intravenous access/sample collection<br>
-:❑ Large-bore cannula <br>
-:❑ Use bottle containing [[EDTA]] anticoagulant (purple color) <br>
-:❑ Avoid using IV site for drugs <br>
-::❑ [[Glucose|Dextrose solution]] (cause [[hemolysis]])<br>
-::❑ [[Calcium]]-containing solutions (cause [[clotting]] of citrated blood)<br>
-❑ '''Precaution against errors'''  <br>
-:❑ Bleed only one patient at a time <br>
-:❑ Ensure two independent patient identifiers <br>
-:❑ Proper labelling of samples <br>
-:❑ Record date and time of blood or blood component <br>
-❑ Bleeding patient  <br>
-:❑ Stop all anticoagulation - [[heparin]], [[warfarin]] <br>
-:❑ Reverse [[anticoagulant]]s, if necessary<br>
-❑ Record vital signs  <br>
-❑ </div>}}
-{{familytree | |,|-|^|-|.| | |}}
-{{familytree | E01 | | E02 | | |E01=Low [[hemoglobin]] level|E02=Coagulopathy}}
-{{familytree | | | |,|-|^|-|.| | |}}
-{{familytree | | | F01 | | F02 | | F01=Low platelets|F02=Coagulation factor deficiency}}
-{{familytree | | | |,|-|-|-|+|-|-|-|.| | |}}
-{{familytree | | | |!| | | |!| | | |!| | |}}
-{{familytree | | | H01 | | H02 | | H03 | |H01=Consider [[fresh frozen plasma]]|H02=Consider [[cryoprecipitate]]|H03=Consider [[prothrombin complex concentrate]]}}
-{{familytree | | | |!| | | |!| | | |!| | |}}
-{{familytree | | | G01 | | G02 | | G03 | |G01=Refractory|G02=Refractory|G03=Refractory}}
-{{familytree/end}}
-===PRBCs===
-{{familytree/start}}
-{{familytree | | | | | | | | | | | A01 | | |A01=<div style="float: left; text-align: left;">'''Low hemoglobin concentration:''' <br>
-<table class="wikitable">
-<tr class="v-firstrow"><th> Parameter</th><th>Men</th><th>Women</th></tr>
-<tr><td>❑ Hb (g/dL)</td><td>❑ 14 - 17.4</td><td>❑ 12.3 - 15.3</td></tr>
-<tr><td>❑ HCT (%)</td><td>❑ 42 - 50</td><td>❑ 36 - 44</td></tr>
-</table>
-</div>}}
-{{familytree | | | | | | | | | | | |!| | | |}}
-{{familytree | | | | | | | | | | | B01 | |B01=<div style="float: left; text-align: left;">'''Review indications to transfuse:''' <br>
-<table class="wikitable">
-<tr class="v-firstrow"><th> Patient category</th><th>Threshold (g/dL)</th></tr>
-<tr><td>❑ Symptomatic patients e.g., <br>[[chest pain]], <br> [[orthostatic hypotension]], [[CHF]], <br>[[tachycardia]] <br> unresponsive to fluids</td><td>❑10<ref name="pmid23708168">{{cite journal| author=Carson JL, Brooks MM, Abbott JD, Chaitman B, Kelsey SF, Triulzi DJ et al.| title=Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. | journal=Am Heart J | year= 2013 | volume= 165 | issue= 6 | pages= 964-971.e1 | pmid=23708168 | doi=10.1016/j.ahj.2013.03.001 | pmc=PMC3664840 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23708168  }} </ref><ref name="pmid22168590">{{cite journal| author=Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG et al.| title=Liberal or restrictive transfusion in high-risk patients after hip surgery. | journal=N Engl J Med | year= 2011 | volume= 365 | issue= 26 | pages= 2453-62 | pmid=22168590 | doi=10.1056/NEJMoa1012452 | pmc=PMC3268062 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22168590  }} </ref></td></tr>
-<tr><td>❑ Hemodynamically stable ICU <br> in-patients (adult and pediatric)</td><td>❑ 7 - 8<ref name="pmid22751760">{{cite journal| author=Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK et al.| title=Red blood cell transfusion: a clinical practice guideline from the AABB*. | journal=Ann Intern Med | year= 2012 | volume= 157 | issue= 1 | pages= 49-58 | pmid=22751760 | doi=10.7326/0003-4819-157-1-201206190-00429 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22751760  }} </ref></td></tr>
-<tr><td>❑ In-patient with preexisting <br>[[cardiovascular disease]]</td><td>❑ ≤ 8 or for symptoms<ref name="pmid22751760">{{cite journal| author=Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK et al.| title=Red blood cell transfusion: a clinical practice guideline from the AABB*. | journal=Ann Intern Med | year= 2012 | volume= 157 | issue= 1 | pages= 49-58 | pmid=22751760 | doi=10.7326/0003-4819-157-1-201206190-00429 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22751760  }} </ref> </td></tr>
-<tr><td>❑ [[Acute coronary syndrome]]s</td><td>❑ < 8<ref name="pmid21873419">{{cite journal| author=Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H et al.| title=ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). | journal=Eur Heart J | year= 2011 | volume= 32 | issue= 23 | pages= 2999-3054 | pmid=21873419 | doi=10.1093/eurheartj/ehr236 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21873419  }} </ref>, 8 - 10<ref name="pmid21791325">{{cite journal| author=Cooper HA, Rao SV, Greenberg MD, Rumsey MP, McKenzie M, Alcorn KW et al.| title=Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study). | journal=Am J Cardiol | year= 2011 | volume= 108 | issue= 8 | pages= 1108-11 | pmid=21791325 | doi=10.1016/j.amjcard.2011.06.014 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21791325  }} </ref></td></tr>
-<tr><td>❑ All patients</td><td>❑ Consider symptoms <br> + Hb level before transfusing<ref name="pmid22751760">{{cite journal| author=Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK et al.| title=Red blood cell transfusion: a clinical practice guideline from the AABB*. | journal=Ann Intern Med | year= 2012 | volume= 157 | issue= 1 | pages= 49-58 | pmid=22751760 | doi=10.7326/0003-4819-157-1-201206190-00429 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22751760  }} </ref></td></tr>
-</table>
-</div>}}
-{{familytree | | | | | | | | | | | |!| | | |}}
-{{familytree | | | | | | | | | | | C01 | |C01=<div style="float: left; text-align: left;">'''Actively bleeding?''' <br>
-❑ Frank bleeding   <br>
-:❑ [[Hematuria]] <br>
-:❑ Bleeding from trauma sites <br>
-:❑ Intraoperative bleeding<br>
-:❑ [[Hematochezia]]<br>
-:❑ [[Hemoptysis]] <br>
-❑ Occult bleeding  <br>
-:❑
-</div>}}
-{{familytree | | | | | | | | |,|-|-|^|-|-|.| | |}}
-{{familytree | | | | | | | | D01 | | | | D02 | |D01='''Yes'''|D02='''No'''}}
-{{familytree | | | | | |,|-|-|^|.| | | |,|^|-|-|.| |}}
-{{familytree | | | | | E01 | | E02 | | E03 | | E04 | |E01='''Asymtomatic'''|E02=<div style="float: left; text-align: left;">'''Symptomatic:''' <br>
-❑  <br>
-❑  <br>
-❑  <br>
 ❑ <br>
 ❑ <br>
-❑ </div>|E03=<div style="float: left; text-align: left;">'''Symptomatic:''' <br>
-❑  <br>
-❑  <br>
-❑  <br>
-❑ </div>|E04='''Asymptomatic'''}}
-{{familytree | | | | | |!| | | |`|-|v|-|'| | | |!| | |}}
-{{familytree | | | | | F01 | | | | F02 | | | | F03 | |F01=Treat|F02=Transfuse packed red blood cells|F03=Treat}}
-{{familytree | | | | | | | |,|-|-|-|+|-|-|-|.| | |}}
-{{familytree | | | | | | | H01 | | H02 | | H03 | |H01=<div style="float: left; text-align: left;">'''Monitoring:''' <br>
-❑  <br>
-❑  <br>
-❑  <br>
 ❑ <br>
 ❑ <br>
-❑  <br>
-❑  <br>
-❑  <br>
-❑  <br>
 ❑ <br>
-❑ </div>|H02=<div style="float: left; text-align: left;">'''Manage complications:''' <br>
-❑  <br>
-❑  <br>
-❑  <br>
 ❑ <br>
 ❑ <br>
-❑  <br>
-❑  <br>
-❑  <br>
-❑  <br>
 ❑ <br>
-❑ </div>|H03=<div style="float: left; text-align: left;">'''Treat underlying cause:''' <br>
-❑  <br>
-❑  <br>
-❑  <br>
 ❑ <br>
 ❑ <br>
-❑  <br>
-❑  <br>
-❑  <br>
-❑  <br>
 ❑ <br>
-❑ </div>}}
+❑
+</div>}}
 {{familytree/end}}

Sandbox/22: Difference between revisions

Revision as of 15:12, 20 March 2014

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