Narrative Review: Myocardial Infarction: Difference between revisions
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| | |mm/dd/YYYY | ||
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== Procedure == | == Procedure == | ||
* '''Index Procedure Date/Time''': | * '''Index Procedure Date/Time''': mm/dd/YYYY at xx:xx [insert date and time] | ||
* '''Index Procedure Detail''': | * '''Index Procedure Detail''': | ||
** On [insert date and time] the subject underwent a [select surgical correction] for [select etiology]. | ** On [insert date and time] the subject underwent a [select surgical correction] for [select etiology]. | ||
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== Event(s)== | == Event(s)== | ||
'''Event (1):''' | '''Event (1):''' | ||
*'''Site Reported Event Onset Date:''' | *'''Site Reported Event Onset Date:''' mm/dd/YYYY | ||
*'''Event summary''': | *'''Event summary''': | ||
**Symptoms and sign: Subject presented with [sign and symptom] on | **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. | **Important characteristics of the chief complaint such as severity, site, and duration. | ||
**Other important symptoms related to the chief compliant. | **Other important symptoms related to the chief compliant. | ||
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***Positive physical examinations or related negative examinations. | ***Positive physical examinations or related negative examinations. | ||
'''Event (2):''' | '''Event (2):''' | ||
*'''Site Reported Event Onset Date:''' | *'''Site Reported Event Onset Date:''' mm/dd/YYYY | ||
*'''Event summary''': | *'''Event summary''': | ||
**Symptoms and sign: Subject presented with [sign and symptom] on | **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. | **Important characteristics of the chief complaint such as severity, site, and duration. | ||
**Other important symptoms related to the chief compliant. | **Other important symptoms related to the chief compliant. | ||
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|'''Troponin nl: (ratio)''' | |'''Troponin nl: (ratio)''' | ||
|- | |- | ||
| | |mm/dd/YYYY | ||
|xx:xx | |xx:xx | ||
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| | |mm/dd/YYYY | ||
|xx:xx | |xx:xx | ||
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| | |mm/dd/YYYY | ||
|xx:xx | |xx:xx | ||
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!Finding | !Finding | ||
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| | |mm/dd/YYYY | ||
|xx:xx | |xx:xx | ||
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|xx:xx | |xx:xx | ||
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|xx:xx | |xx:xx | ||
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Revision as of 19:36, 14 June 2018
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 |
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: mm/dd/YYYY 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: 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:
- Troponin levels and timing:
Date | Time | CKMB nl: (ratio) | Troponin nl: (ratio) |
mm/dd/YYYY | xx:xx | ||
mm/dd/YYYY | xx:xx | ||
mm/dd/YYYY | xx:xx |
- Other laboratory:
- Date/ name/ value [ as a list ]
- Other laboratory:
- ECG’s:
Date | Time | Finding |
---|---|---|
mm/dd/YYYY | xx:xx | |
mm/dd/YYYY | xx:xx | |
mm/dd/YYYY | xx:xx |
- ECHO/ date:
- Trans-thoracic:
- Trans-esophagus:
- CXR / date:
- Other relevant 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]