Narrative Review: Major Bleeding: Difference between revisions
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==Demographic / Medical history== | |||
== Demographic / Medical history == | *'''Demographic:''' [age] year old [gender] | ||
* [age] year old [gender] | *'''Past Medical History:''' [eg. CAD, Severe mitral stenosis, former tobacco use, dyslipidemia, ...] | ||
* '''Past Medical History:''' [eg. | *'''Past Surgical History:''' [including date] | ||
* '''Past Surgical History:''' [including date] | *'''Medications:''' [relevant to the event not all] | ||
== Procedure == | == Procedure == | ||
* '''Index Procedure Date/Time''': | * '''Index Procedure Date/Time''': | ||
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|'''HGB''' | |'''HGB''' | ||
|'''HTC''' | |'''HTC''' | ||
|'''PLT''' | |||
|'''INR''' | |'''INR''' | ||
|'''PT/PTT''' | |'''PT/PTT''' | ||
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|xx/xx/xxx | |xx/xx/xxx | ||
|xx:xx | |xx:xx | ||
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|xx/xx/xxx | |xx/xx/xxx | ||
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Revision as of 19:18, 14 June 2018
| Site | Patient | AE | Complication | Event date | AE code |
|---|---|---|---|---|---|
| xxx | xxx | x | xx/xx/xxxx | xxx |
Demographic / Medical history
- Demographic: [age] year old [gender]
- 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:
- 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].
- Access site details
- 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:
- 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
- Other relevant laboratory tests:
- 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
- Out come [Discharge / Hospice / Death]