Narrative Review: Acute Kidney Injury: Difference between revisions

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'''Site:'''  
{| class="wikitable"
!'''Site'''
!'''Patient'''
!'''AE'''
!'''Complication'''
!'''Event date'''
!'''AE code'''
|-
|'''xxx'''
|'''xxx'''
|'''x'''
|
|'''xx/xx/xxxx'''
|'''xxx'''
|}
==Demographic / Medical history==
*[age] year old [gender]
*'''Past Medical History:''' [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
*'''Past Surgical History:''' [including date]
==Procedure==
*'''Index Procedure Date/Time''': xx/xx/xxxx at xx:xx  [insert date and time]
*'''Index Procedure Detail''':
**On [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
**Enter access site details
**Baseline MR severity was classified as [select none, trace, mild, mild-moderate, moderate, moderate-severe-severe] and post-implant MR was classified as [select severity].
**The site reported that there were/were not procedural complication(s).
==Event(s)==
'''Event (1):'''
*'''Site Reported Event Onset Date:''' xx/xx/xxxx


'''AE:'''
*'''Event summary''':
**Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
**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:''' xx/xx/xxxx
*'''Event summary''':
**Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
**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.


'''Complication:'''
== Laboratory data and Imaging ==
 
'''Event date:'''
 
'''Adverse event code:'''
* '''Demograghic''': [age] year old [gender]
* '''Past Medical History:''' [eg. diabetes, CAD,...]
* '''Index Procedure Date/Time''': xx/xx/xxxx at xx:xx  [insert date and time]
* '''Index Procedure Detail''': 
** On xx/xx/xxxx at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
** Enter access site details
** The site reported that there were/were not procedural complication(s).
* '''Event''': MI
* '''Site Reported Event Onset Date:''' xx/xx/xxxx
* '''Event summary''':
** Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
** 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.
* '''Lab studies:'''
* '''Lab studies:'''
** Bun/Cr levels  
** Bun/Cr levels  
Line 60: Line 83:
* '''CXR / date:'''  
* '''CXR / date:'''  
* '''Other imaging and diagnostic tests / date:'''
* '''Other imaging and diagnostic tests / date:'''
* '''Consults:'''
==Consults==
** Date / result:
*Date and time of consult
* '''Clinical course''':
*Suggested treatments
* '''Dialysis:'''
==Clinical course==
*# xx/xx/xxxx at xx:xx 
*Date and time of events,
*# xx/xx/xxxx at xx:xx 
*Dialysis / time
*# xx/xx/xxxx at xx:xx 
*Patient condition got worse or better.
*# xx/xx/xxxx at xx:xx 
==Treatment and outcome==
 
*List of relevant medical treatments
* '''Treatment / date:'''
*Out come [Discharge / Hospice / Death]
* '''Outcome:''' [Discharge / Hospice / Death]

Revision as of 18:09, 14 June 2018

Site Patient AE Complication Event date AE code
xxx xxx x xx/xx/xxxx xxx

Demographic / Medical history

  • [age] year old [gender]
  • Past Medical History: [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...]
  • Past Surgical History: [including date]

Procedure

  • Index Procedure Date/Time: xx/xx/xxxx at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Enter access site details
    • Baseline MR severity was classified as [select none, trace, mild, mild-moderate, moderate, moderate-severe-severe] and post-implant MR was classified as [select severity].
    • The site reported that there were/were not procedural complication(s).

Event(s)

Event (1):

  • Site Reported Event Onset Date: xx/xx/xxxx
  • Event summary:
    • Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
    • 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: xx/xx/xxxx
  • Event summary:
    • Symptoms and sign: Subject presented with [sign and symptom] on xx/xx/xxxx.
    • 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:
    • Bun/Cr levels
Date Time BUN/Cr Na/K Urine output
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx
    • Other labratory:
      • 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,
  • Dialysis / time
  • Patient condition got worse or better.

Treatment and outcome

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