Narrative Review: Major Bleeding: Difference between revisions

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{{Narrative Review}}
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==Demographic / Medical history==
== Diagnosis==
*'''Demographic:''' [age] year old [gender]
'''Addmission date:''' MM/DD/YYYY
*'''Past Medical History:''' [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
*'''Past Surgical History:''' [including date]
*'''Medications:''' [relevant to the event not all]
== Procedure ==
* '''Index Procedure Date/Time''':
** mm/dd/YYYY at xx:xx  [insert date and time]
* '''Index Procedure Detail''': 
** On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
** Access site details
** The site reported that there were/were not procedural complication(s).
 
== Event(s) ==
'''Event (1):'''
* '''Site Reported Event Onset Date:''' mm/dd/YYYY
 
* '''Event summary''':
** Symptoms and sign: Subject presented with [sign and symptom] on mm/dd/YYYY.
** Important characteristics of the chief complaint such as severity, site, and duration.
** Other important symptoms related to the chief compliant.
** Physical assessment:
*** Vital signs
*** Positive physical examinations or related negative examinations.
'''Event (2):'''
*'''Site Reported Event Onset Date:''' mm/dd/YYYY
* '''Event summary''':
** Symptoms and sign: Subject presented with [sign and symptom] on mm/dd/YYYY.
** Important characteristics of the chief complaint such as severity, site, and duration.
** Other important symptoms related to the chief compliant.
** Physical assessment:
*** Vital signs
*** Positive physical examinations or related negative examinations.


== Laboratory data and Imaging ==
* '''Lab studies:'''
** CBC, INR, and PT/PTT:
{| class="wikitable"
{| class="wikitable"
|'''Date'''
|'''Date'''
|'''Time'''
|'''Time'''
|'''HGB'''
|'''HgB'''
|'''HTC'''
|'''HTC'''
|'''PLT'''
|'''PLT'''
|'''INR'''
|'''INR'''
|'''PT/PTT'''
|'''PT/PTT'''
|'''Transfusion (Units/24hr)'''
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|-
|xx/xx/xxx
|xx/xx/xxx
|xx:xx
|xx:xx
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== Major Bleeding ==
An episode of suspected internal or external bleeding that results in one or more of the following:
O Death
O Re-operation
O Hospitalization
O Transfusion of red blood cells as follows:
==== During first 7 days post implant ====
* Adults (≥ 50 kg):  ≥ 4U packed red blood cells (PRBC) within any 24 hour period during first 7 days post implant.
==== After 7 days post implant ====
* Any transfusion of packed red blood cells (PRBC) after 7 days following implant with the investigator recording the number of units given. (record number of units given per 24 hour period).
Note: Hemorrhagic stroke is considered a neurological event and not as a separate bleeding event.
== Event ==
'''Demographic:''' [age] year old [gender]
'''Site Reported Event Onset Date:''' MM/DD/YYYY
'''Event summary''':
*'''Symptoms and sign''':
**Subject presented with [sign and symptom] on MM/DD/YYYY.
**Important characteristics of the chief complaint such as severity, site, and duration.
**Other important symptoms related to the chief complaint.
*'''Past Medical History:''' [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
*'''Past Surgical History:''' [including date]
*'''Medications:''' [relevant to the event not all]
*'''Physical assessment:'''
**Vital signs
**Positive physical examinations or related negative examinations.
'''Event (2): [If there is more than 1 event]'''
==Procedure==
*'''Index Procedure Date/Time''':
**mm/dd/YYYY at xx:xx  [insert date and time]
*'''Index Procedure Detail''':
**On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
**Access site details
**The site reported that there were/were not procedural complication(s). 
== Laboratory data and Imaging ==
* '''Lab studies:'''
** CBC, INR, and PT/PTT:
** Other relevant laboratory tests:
** Other relevant laboratory tests:
*** Date/ name/ value
*** Date/ name/ value
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* '''CXR / date:'''  
* '''CXR / date:'''  
* '''Other imaging and diagnostic tests / date:'''
* '''Other imaging and diagnostic tests / date:'''
==Consults==
==Consults==
*Date and time of consult
*Date and time of consult
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==Treatment and outcome==
==Treatment and outcome==
*List of relevant medical treatments
*List of relevant medical treatments
*Out come [Discharge / Hospice / Death]
*Outcome [Discharge / Hospice / Death]

Latest revision as of 01:00, 27 June 2018

Narrative Review

Narrative Review: Death

Narrative Review: Stroke

Narrative Review: Myocardial Infarction

Narrative Review: Acute Kidney Injury

Narrative Review: Bleeding

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Site Patient AE Complication Event date AE code
xxx xxx x mm/dd/YYYY xxx

 Diagnosis

Addmission date: MM/DD/YYYY

Date Time HgB HTC PLT INR PT/PTT Transfusion (Units/24hr)
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx

Major Bleeding

An episode of suspected internal or external bleeding that results in one or more of the following:

O Death

O Re-operation

O Hospitalization

O Transfusion of red blood cells as follows:

During first 7 days post implant

  • Adults (≥ 50 kg):  ≥ 4U packed red blood cells (PRBC) within any 24 hour period during first 7 days post implant.

After 7 days post implant

  • Any transfusion of packed red blood cells (PRBC) after 7 days following implant with the investigator recording the number of units given. (record number of units given per 24 hour period).

Note: Hemorrhagic stroke is considered a neurological event and not as a separate bleeding event.

Event

Demographic: [age] year old [gender]

Site Reported Event Onset Date: MM/DD/YYYY

Event summary:

  • Symptoms and sign:
    • Subject presented with [sign and symptom] on MM/DD/YYYY.
    • Important characteristics of the chief complaint such as severity, site, and duration.
    • Other important symptoms related to the chief complaint.
  • Past Medical History: [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
  • Past Surgical History: [including date]
  • Medications: [relevant to the event not all]
  • Physical assessment:
    • Vital signs
    • Positive physical examinations or related negative examinations.

Event (2): [If there is more than 1 event]

Procedure

  • Index Procedure Date/Time:
    • mm/dd/YYYY at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Access site details
    • The site reported that there were/were not procedural complication(s). 

Laboratory data and Imaging

  • Lab studies:
    • CBC, INR, and PT/PTT:
    • Other relevant laboratory tests:
      • Date/ name/ value
  • ECG / date:
  • ECHO / date:
  • CXR / date:
  • Other imaging and diagnostic tests / date:

Consults

  • Date and time of consult
  • Suggested treatments

Clinical course

  • Date and time of events,
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
  • Outcome [Discharge / Hospice / Death]
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