Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for celiac artery aneurysm (CAA) or evaluation of new symptoms suggestive of CAA.
SOAP
Subjective (S):
Symptoms (if applicable):
Inquire about any new or worsening abdominal pain, particularly in the upper left quadrant.
Explore for nausea, vomiting, early satiety (feeling full quickly after eating), or back pain.
Ask about unintentional weight loss or any recent changes in bowel habits.
Past Medical History:
Briefly summarize relevant past medical history, including:
Comorbidities like hypertension, hyperlipidemia, or atherosclerotic disease.
Previous diagnoses of CAA or other vascular diseases.
Smoking history (significant risk factor for CAA).
Past Surgical History:
Note any prior abdominal surgeries that might be relevant to imaging studies.
Objective (O):
Physical Exam:
Perform a focused abdominal exam to assess for:
Pulsatile abdominal mass in the upper left quadrant (uncommon finding)
Abdominal tenderness or distention
Signs of chronic liver disease (if complications like portal hypertension are present)
Vascular Exam:
Briefly document the presence or absence of bruits over the aorta and celiac artery (auscultation may not be reliable for CAA diagnosis).
Assessment (A):
Diagnosis:
Indicate the presence or suspicion of CAA based on:
Imaging studies (see below)
Clinical presentation (symptoms are often vague and non-specific)
If CAA is confirmed, estimate the size of the aneurysm based on imaging results.
Complications (if applicable):
Consider potential complications of CAA, such as:
Rupture (life-threatening)
Thrombosis (clot formation within the aneurysm)
Compression of surrounding structures (e.g., stomach, duodenum) leading to gastrointestinal symptoms
Differential Diagnosis:
Briefly mention other conditions that might cause similar symptoms (e.g., peptic ulcer disease, pancreatitis, cholecystitis).
Plan (P):
Imaging Studies:
Imaging is crucial for CAA diagnosis and management. Depending on the clinical scenario, consider:
Ultrasound (Doppler ultrasound): Initial non-invasive test to evaluate blood flow and identify potential aneurysms.
CT angiography: More detailed imaging to confirm CAA diagnosis, assess aneurysm size and location, and evaluate for complications.
Magnetic resonance angiography (MRA): Alternative to CT angiography, particularly in younger patients or those with contraindications to iodinated contrast.
Management Strategy:
The management approach for CAA depends on the size, presence of symptoms, and risk of complications. Discuss with the patient the following options:
Observation: For small, asymptomatic aneurysms, close monitoring with serial imaging might be sufficient.
Endovascular Repair: Minimally invasive procedure using a stent graft to exclude the aneurysm from blood flow.
Open Surgical Repair: Traditional surgery with removal of the aneurysm and reconstruction of the celiac artery.
Risk Factor Management:
Emphasize the importance of managing cardiovascular risk factors like hypertension, hyperlipidemia, and smoking cessation to slow aneurysm growth and prevent complications.
Follow-up:
Schedule follow-up appointments based on the management plan. For patients on observation, this might involve repeat imaging at specific intervals.
If intervention is planned, discuss the details of the procedure and potential risks and benefits.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., vascular surgeon)
Need for additional testing (e.g., laboratory tests to assess for risk factors)
Discussion of the patient’s preferences regarding treatment options
Educational resources provided to the patient about CAA and its management