Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for cervical artery dissection (CAD) or evaluation of new symptoms.
SOAP
Subjective (S):
History of Present Illness:
Briefly summarize the initial presentation of CAD, including:
Onset and duration of symptoms (headache, neck pain, dizziness, transient ischemic attack [TIA] symptoms).
Laterality of symptoms (if applicable).
Any recent history of trauma (minor or major) to the neck.
Current Symptoms:
Inquire about any changes in symptoms since the last visit, including:
Improvement or worsening of headache, neck pain, or dizziness
New neurological symptoms suggestive of stroke (weakness, numbness, speech difficulties, vision changes)
Past Medical History:
Briefly summarize relevant past medical history, including:
Risk factors for CAD (e.g., hypertension, hyperlipidemia, connective tissue disease)
Previous history of CAD or stroke
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Neurological Exam:
Perform a focused neurological exam to assess:
Mental status (alertness, orientation)
Cranial nerves
Motor function (strength, coordination)
Sensory function
Language skills
Gait and balance
Compare findings to previous exams to identify any changes suggestive of neurological deficits.
Vascular Exam (if indicated):
Briefly document findings from carotid auscultation (listening for bruits over the carotid arteries) if performed.
Assessment (A):
Clinical Course:
Based on the subjective and objective findings, assess the overall clinical course of the CAD.
Is the patient improving, stable, or worsening?
Neurological Status:
Describe any new or worsening neurological deficits based on the neurological exam.
Imaging Follow-up (if available):
Briefly summarize findings from recent imaging studies (e.g., CTA, MRA) if performed:
Persistence or resolution of arterial dissection
Any evidence of stroke or ischemia
Plan (P):
Medical Management:
Depending on the severity and presentation of CAD, the plan may include:
Antiplatelet medications (e.g., aspirin, clopidogrel) to prevent blood clots.
Anticoagulation therapy (e.g., warfarin) in specific cases.
Blood pressure control medications if needed.
Management of other risk factors like hyperlipidemia.
Imaging Follow-up:
Schedule follow-up imaging studies (CTA, MRA) at appropriate intervals to monitor for changes in the dissection and potential complications.
Lifestyle Modifications:
Advise smoking cessation and a healthy lifestyle to reduce cardiovascular risk.
Physical Therapy (if indicated):
Consider referral for physical therapy to address any neurological deficits or movement limitations.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., neurologist, vascular surgeon)
Discussion of the potential risks and benefits of treatment options
Importance of close follow-up to monitor for complications like stroke
Education regarding warning signs and symptoms of stroke
Potential need for rehabilitation therapy for long-term neurological deficits