Narrative Review: Major Bleeding: Difference between revisions
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== | == Diagnosis== | ||
'''Addmission date:''' MM/DD/YYYY | '''Addmission date:''' MM/DD/YYYY | ||
{| class="wikitable" | {| class="wikitable" | ||
|'''Date''' | |'''Date''' | ||
|'''Time''' | |'''Time''' | ||
|''' | |'''HgB''' | ||
|'''HTC''' | |'''HTC''' | ||
|'''PLT''' | |'''PLT''' | ||
|'''INR''' | |'''INR''' | ||
|'''PT/PTT''' | |'''PT/PTT''' | ||
|'''Transfusion (Units/24hr)''' | |||
|- | |- | ||
|xx/xx/xxx | |xx/xx/xxx | ||
|xx:xx | |xx:xx | ||
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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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== Major Bleeding == | |||
An episode of suspected internal or external bleeding that results in one or more of the following: | |||
O Death | |||
O Re-operation | |||
O Hospitalization | |||
O Transfusion of red blood cells as follows: | |||
==== During first 7 days post implant ==== | |||
* Adults (≥ 50 kg): ≥ 4U packed red blood cells (PRBC) within any 24 hour period during first 7 days post implant. | |||
==== After 7 days post implant ==== | |||
* Any transfusion of packed red blood cells (PRBC) after 7 days following implant with the investigator recording the number of units given. (record number of units given per 24 hour period). | |||
Note: Hemorrhagic stroke is considered a neurological event and not as a separate bleeding event. | |||
== Event == | |||
'''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: | |||
** Other relevant laboratory tests: | ** Other relevant laboratory tests: | ||
*** Date/ name/ value | *** Date/ name/ value | ||
| Line 90: | Line 115: | ||
* '''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 | ||
Latest revision as of 01:00, 27 June 2018
|
Narrative Review |
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 |
Diagnosis
Addmission date: MM/DD/YYYY
| Date | Time | HgB | HTC | PLT | INR | PT/PTT | Transfusion (Units/24hr) |
| xx/xx/xxx | xx:xx | ||||||
| xx/xx/xxx | xx:xx | ||||||
| xx/xx/xxx | xx:xx |
Major Bleeding
An episode of suspected internal or external bleeding that results in one or more of the following:
O Death
O Re-operation
O Hospitalization
O Transfusion of red blood cells as follows:
During first 7 days post implant
- Adults (≥ 50 kg): ≥ 4U packed red blood cells (PRBC) within any 24 hour period during first 7 days post implant.
After 7 days post implant
- Any transfusion of packed red blood cells (PRBC) after 7 days following implant with the investigator recording the number of units given. (record number of units given per 24 hour period).
Note: Hemorrhagic stroke is considered a neurological event and not as a separate bleeding event.
Event
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:
- 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]