Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for cerebral venous thrombosis (CVT) or evaluation of new neurological symptoms.
SOAP
Subjective (S):
History of Present Illness:
Briefly summarize the underlying cause of CVT, if known (e.g., dehydration, pregnancy, hypercoagulable state, local infection).
Inquire about any recent changes in neurological symptoms, including:
Headache (worsening or new onset) – often described as severe and throbbing
Seizures
Weakness or numbness (may be one-sided)
Confusion
Vision changes (blurred vision, double vision)
Speech or language difficulties
Difficulty with coordination or balance
Dizziness
Past Medical History:
Briefly summarize relevant past medical history, including:
Conditions that increase risk of CVT (e.g., thrombophilia, recent surgery or infection)
Previous episodes of CVT or blood clots
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate. Assess for signs of increased intracranial pressure (ICP) like elevated blood pressure and bradypnea (slow breathing).
Neurological Exam:
Perform a focused neurological exam to assess:
Level of consciousness (alertness)
Pupillary response (size and reactivity to light)
Motor function (strength, coordination)
Sensory function
Language skills
Gait and balance
Compare findings to previous exams to identify any changes suggestive of worsening CVT.
Fundoscopy (if performed):
Briefly document findings, such as papilledema (swollen optic nerve) which can be a sign of increased ICP.
Assessment (A):
Severity of CVT:
Based on clinical presentation, imaging studies (if available), and neurological exam findings, assess the severity of CVT.
Location of Thrombosis:
If imaging studies are available, describe the location of the cerebral venous sinus thrombosis.
Response to Treatment (if applicable):
If the patient is already on treatment for CVT, evaluate the response based on:
Improvement in neurological symptoms
Trends in vital signs, particularly blood pressure
Imaging Studies:
Briefly describe relevant findings from recent imaging studies like CT venogram or MRI venogram, such as:
Evidence of thrombosis in cerebral venous sinuses
Presence of edema or hemorrhage
Plan (P):
Anticoagulation Therapy:
Initiate or adjust anticoagulation therapy based on severity, location of CVT, and risk factors for bleeding.
Thrombolysis (if indicated):
Consider thrombolysis (clot-busting medication) for high-risk CVT with rapid neurological decline in close consultation with a neurointerventionalist.
Management of Underlying Cause (if identified):
Address the underlying cause of CVT, if possible (e.g., antibiotics for infection, treatment of dehydration).
Neurological Monitoring:
Consider serial neurological exams and imaging follow-up to monitor for complications like hemorrhage or progression of edema.
Supportive Care:
Maintain adequate hydration and electrolyte balance.
Manage pain (particularly headache) as needed.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., neurologist, neurosurgeon, hematologist)
Prognosis discussion with the patient and family based on the severity of CVT and underlying cause
Risks and benefits of various treatment options
Importance of close monitoring to prevent complications
Potential need for rehabilitation therapy for neurological deficits
Prophylaxis for future blood clots based on risk factors