Narrative Review: Major Bleeding: Difference between revisions

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

Revision as of 14:41, 21 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

 Event

Addmission date: MM/DD/YYYY

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:
Date Time HGB HTC PLT INR PT/PTT
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx
xx/xx/xxx xx:xx
    • 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]