Date:
Patient:
Reason for Visit: Follow-up for subclavian and/or brachiocephalic artery stenosis
History of Present Illness:
Onset and description of symptoms (e.g., vertebrobasilar insufficiency symptoms – dizziness, vertigo, drop attacks, visual disturbances; arm weakness, fatigue, claudication in the arm)
Risk factors for atherosclerosis (hypertension, hyperlipidemia, smoking, diabetes)
History of previous vascular events (stroke, myocardial infarction)
Physical Exam:
Vital signs (blood pressure, assess for asymmetry in brachial artery pulses)
Carotid bruits (may be present if stenosis is severe)
Neurological exam (if vertebrobasilar symptoms present)
Peripheral artery exam (assess for pulses in upper extremities, including subclavian and radial pulses)
Labs:
Basic metabolic panel (BMP) to assess for risk factors
Lipid panel
Imaging:
Mention the type of imaging used to diagnose stenosis (e.g., carotid artery Doppler ultrasound, CT angiography, MRA)
Describe the location and severity (% stenosis) of the subclavian and/or brachiocephalic artery stenosis
Diagnosis:
Subclavian artery stenosis (mention right or left) with % stenosis
Brachiocephalic artery stenosis with % stenosis
Mention any additional diagnoses (e.g., vertebrobasilar insufficiency)
Management:
Summarize the current treatment plan:
Medical management: Address risk factors with medications (antihypertensives, statins, antiplatelet agents)
Lifestyle modifications: Smoking cessation, weight management, exercise program
Consider mentioning future interventions depending on severity and symptoms (e.g., carotid artery stenting (CAS), carotid endarterectomy (CEA))
Consultation:
Document any consultations with specialists (vascular surgery, interventional radiology)
Plan:
Outline the plan for the next day(s):
Monitoring of symptoms
Repeat blood pressure measurements
Consideration for repeat imaging depending on clinical course
Education on risk factor modification and medication adherence
Schedule for follow-up visits
Prognosis:
Briefly discuss the prognosis based on severity of stenosis, response to treatment, and presence of symptoms.
Mention potential complications of untreated stenosis (stroke, transient ischemic attack (TIA))
Additional Information:
Document the Ankle-Brachial Index (ABI) if measured.
Note any limitations in activities due to symptoms.