Narrative Review: Major Bleeding: Difference between revisions

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* '''CXR / date:'''  
* '''CXR / date:'''  
* '''Other imaging and diagnostic tests / date:'''
* '''Other imaging and diagnostic tests / date:'''
== Consults==
==Consults==
*Date and time of consult
*Date and time of consult
*Suggested treatments
*Suggested treatments

Revision as of 19:31, 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 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
  • 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]