Narrative Review: Major Bleeding: Difference between revisions

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*'''Past Surgical History:''' [including date]
*'''Past Surgical History:''' [including date]
*'''Medications:''' [relevant to the event not all]
*'''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(s) ==
'''Event (1):'''
'''Event (1):'''
Line 36: Line 28:


* '''Event summary''':
* '''Event summary''':
** Symptoms and sign: Subject presented with [sign and symptom] on mm/dd/YYYY.
** '''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 complaint.
** Other important symptoms related to the chief complaint.
** Physical assessment:
** '''Physical assessment:'''
*** Vital signs  
*** Vital signs  
*** Positive physical examinations or related negative examinations.  
*** Positive physical examinations or related negative examinations.  
Line 45: Line 37:
*'''Site Reported Event Onset Date:''' mm/dd/YYYY
*'''Site Reported Event Onset Date:''' mm/dd/YYYY
* '''Event summary''':  
* '''Event summary''':  
** Symptoms and sign: Subject presented with [sign and symptom] on mm/dd/YYYY.  
** '''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 complaint.
** Physical assessment:
** '''Physical assessment:'''
*** Vital signs  
*** Vital signs  
*** Positive physical examinations or related negative examinations.  
*** 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 20:59, 19 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

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]

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 complaint.
    • 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 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

  • 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]
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