Narrative Review: Stroke: Difference between revisions

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Revision as of 18:31, 14 June 2018

Site Patient AE Complication Event date AE code
xxx xxx x xx/xx/xxxx xxx

Demographic / Medical history

  • [age] year old [gender]
  • Past Medical History: [eg. VHD, anticoagulant usage, diabetes, and CAD,.../ including date]
  • Past Surgical History: [including date]

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, Imaging and tests

  • Lab studies:
    • Date/ name/ value

Diagnostic tests

  • xx/xx/xxxx at xx:xx on brain MRI
  • xx/xx/xxxx at xx:xx on MRA
  • xx/xx/xxxx at xx:xx on CT
  • xx/xx/xxxx at xx:xx on EEG
  • xx/xx/xxxx at xx:xx on Carotid US
  • xx/xx/xxxx at xx:xx on ECG:
  • xx/xx/xxxx at xx:xx on ECHO:
  • xx/xx/xxxx at xx:xx on Ultrasound:
  • xx/xx/xxxx at xx:xx on Endoscopy:
  • xx/xx/xxxx at xx:xx ... (Other relevant imaging and diagnostic tests)

 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]