Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be a follow-up visit for a known AAA, evaluation of new symptoms suggestive of AAA, or post-operative management following AAA repair.
History of Present Illness (HPI)
Focus on any new or worsening symptoms that might be related to the AAA.
Examples: abdominal pain, pulsatile abdominal mass, back pain, leg pain, difficulty walking.
Mention the duration, severity, and any aggravating or alleviating factors for the symptoms.
Past Medical History (PMHx)
Briefly mention any relevant past medical history, including:
Hypertension
Coronary artery disease
Peripheral arterial disease
Smoking history
Chronic obstructive pulmonary disease (COPD)
Previous abdominal surgery
Social History (SHx)
Briefly mention smoking history (current or past)
Family History (FHx)
Mention any family history of AAA in first-degree relatives.
Medications
List all current medications the patient is taking.
Allergies
Document any known allergies, especially to medications.
Physical Examination
General: Assess overall health and any signs of distress.
Vital Signs: Document blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
Abdomen:
Inspect for any visible pulsatile masses.
Palpate for abdominal tenderness, pulsatile masses, or bruits (abnormal sounds) over the aorta.
Assess for distension or asymmetry.
Assessment
Summarize the key findings from the history and physical examination.
State whether the AAA is known or suspected based on this encounter.
If a known AAA is being monitored, mention the current size and any changes since the last evaluation.
Formulate a differential diagnosis if the diagnosis of AAA is uncertain.
Plan
Outline the next steps in the patient’s management. This may include:
Imaging Studies:
Mention the specific imaging study planned (e.g., ultrasound, CT angiogram) to confirm or evaluate the AAA.
Referral to Vascular Surgery: If AAA is confirmed or suspected, referral to a vascular surgeon for further evaluation and possible intervention (repair) should be documented.
Serial Monitoring: If the AAA is small and asymptomatic, serial monitoring with imaging at regular intervals may be recommended.
Management of Risk Factors:
Outline recommendations for managing risk factors like smoking cessation, blood pressure control, and treatment of other relevant medical conditions.
Pain Management: If the patient is experiencing pain, mention the planned pain management strategy (medications, etc.).
Patient Education:
Briefly document patient education regarding AAA, risk factors, warning signs and symptoms, and the importance of follow-up.
Additional Considerations
Adapt this template based on the specific situation (known vs. suspected AAA, pre-operative vs. post-operative management).
Use clear and concise language while maintaining medical accuracy.
Document any discussions or shared decision-making with the patient regarding the plan.
This template provides a framework for documenting progress notes for patients with known or suspected AAA. Remember to tailor it to your specific workflow and facility’s documentation standards.