Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CTEPH, evaluation of symptoms, hemodynamic assessment, medication management, or planning for pulmonary thromboendarterectomy (PTE).
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of symptoms:
Shortness of breath (dyspnea), at rest and with exertion (hallmark symptom of CTEPH)
Fatigue
Chest pain
Dizziness or syncope (fainting)
Ankle swelling (edema)
Worsening of symptoms over time
Past Medical History:
Briefly summarize relevant past medical history, including:
History of deep vein thrombosis (DVT) or pulmonary embolism (PE) – known risk factors for CTEPH
Interval since the initial PE event
Previous treatments for DVT/PE (anticoagulation)
Presence of co-morbidities (e.g., chronic obstructive pulmonary disease (COPD), heart failure)
Social History:
Inquire about any risk factors for DVT/PE (e.g., prolonged immobilization, surgery, hypercoagulable states).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation (SpO2).
Assess for jugular venous distention (JVD) – a sign of elevated right heart pressure.
Physical Exam:
Assess for:
Peripheral edema
Signs of right heart failure (e.g., hepatomegaly)
Electrocardiogram (ECG):
Review ECG findings for signs of right heart strain.
Chest X-ray:
Review chest X-ray for cardiomegaly (enlarged heart).
Echocardiogram (Echo):
Summarize key findings from echocardiography, which can assess right ventricular function and estimate pulmonary artery pressures.
Right Heart Catheterization (RHC) (if performed):
Describe the results of RHC, the gold standard for diagnosing CTEPH and measuring pulmonary artery pressures.
Assessment (A):
Functional Class (WHO):
Classify the patient’s functional class based on WHO classification system, which reflects the severity of symptoms and exercise tolerance.
Hemodynamic Assessment:
Integrate findings from physical exam, Echo, and RHC (if performed) to assess pulmonary artery pressures and right ventricular function.
Operability for Pulmonary Thromboendarterectomy (PTE):
Assess the patient’s suitability for PTE based on hemodynamics, comorbidities, and surgical risk factors.
Plan (P):
Medical Management:
Optimize medical management with pulmonary vasodilator medications to improve symptoms and right heart function.
Consider anticoagulation therapy to prevent further blood clots.
Pulmonary Thromboendarterectomy (PTE) (if indicated):
Discuss the possibility of PTE, a surgical procedure to remove chronic blood clots from pulmonary arteries, as a potential curative option.
Explain the benefits, risks, and potential recovery course of PTE.
Referral (if indicated):
Consider referral to a pulmonary hypertension specialist or cardiothoracic surgeon for patients with severe CTEPH or those deemed candidates for PTE.
Follow-up:
Schedule follow-up visits to monitor symptoms, functional status, hemodynamics with serial Echos or RHCs, and response to treatment.
Define the frequency of follow-up based on disease severity, hemodynamics, and treatment plan.
Patient Education:
Educate the patient about CTEPH, its causes, risk factors, and the importance of treatment adherence.
Discuss the rationale for medications and potential side effects.
Explain the role of pulmonary rehabilitation in managing symptoms and improving exercise tolerance.
If PTE is a possibility, provide information on the surgery, its benefits and risks, and the importance of preoperative evaluation.
Offer resources for support groups or educational materials on managing CTEPH.