Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CMI, evaluation of worsening abdominal pain, diagnostic workup, or treatment planning.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of abdominal pain:
Location, character, duration, and severity of pain (postprandial pain – worsens after meals is suggestive)
Frequency and timing of pain episodes (often occurs 15-30 minutes after meals and improves with fasting)
Weight loss (unintentional weight loss can be a sign of CMI)
Nausea, vomiting, or change in bowel habits
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying vascular disease (atherosclerosis)
Risk factors for atherosclerosis (diabetes, hypertension, hyperlipidemia, smoking)
Previous abdominal surgeries
History of other gastrointestinal conditions (e.g., peptic ulcer disease)
Social History:
Inquire about smoking history (smoking cessation is crucial for CMI management).
Ask about dietary habits and any recent changes.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Abdominal Exam:
Assess for:
Abdominal tenderness or distention
Bowel sounds (may be diminished or absent in severe cases)
Bruits (abnormal sounds over arteries) – may indicate stenosis in mesenteric vessels
Laboratory Tests (review recent results):
Complete blood count (CBC) – may show anemia if chronic blood loss is present.
Electrolytes – assess for dehydration or malnutrition.
Consider additional tests as indicated:
Inflammatory markers (ESR, CRP) – may be elevated in some cases of CMI.
Liver function tests (LFTs) – may be abnormal if there is liver congestion.
Assessment (A):
Severity of CMI:
Assess the severity of CMI based on symptoms, physical exam findings, and impact on daily life.
Differential Diagnosis:
Consider other conditions that can cause abdominal pain (e.g., peptic ulcer disease, irritable bowel syndrome) and differentiate them from CMI based on history, physical exam, and diagnostic tests.
Plan (P):
Diagnostic Workup (if not already performed):
Consider imaging studies to visualize mesenteric vessels and assess blood flow:
Abdominal angiography (gold standard for diagnosis)
CT angiography (less invasive but may require contrast)
Doppler ultrasound (non-invasive but may not be definitive)
Treatment Plan:
Develop a treatment plan based on the severity of CMI and individual needs. Options may include:
Lifestyle Modifications:
Smoking cessation is essential.
Medical management of risk factors (diabetes, hypertension, hyperlipidemia).
Dietary modifications – may include a low-fat diet with smaller, more frequent meals to reduce postprandial stress on mesenteric vessels.
Medications:
Anticoagulant medications (e.g., aspirin) to prevent blood clots.
Vasodilators (to improve blood flow – limited role in CMI management).
Revascularization Procedures (for severe cases):
Angioplasty with stenting
Bypass surgery (considered in select cases)
Referral (if indicated):
Consider referral to a vascular surgeon for evaluation of revascularization procedures or a gastroenterologist for further management.
Follow-up:
Schedule follow-up visits to monitor symptoms, response to treatment, and assess for complications (e.g., bowel infarction).
Define the frequency of follow-up based on the severity of CMI, treatment plan, and presence of symptoms.
Patient Education:
Educate the patient about CMI, its causes, risk factors, and the importance of treatment adherence.
Discuss the importance of lifestyle modifications, particularly smoking cessation and dietary changes.
Explain the rationale for diagnostic tests and potential treatment options (if applicable).
Offer resources for support groups or educational materials on managing CMI.