Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for Chiari malformation, evaluation of new symptoms, or surgical consultation.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the reason for the visit. This may include:
For established diagnosis: New or worsening symptoms suggestive of Chiari malformation, such as:
Headache (often occipital, worsening with coughing or straining)
Dizziness or vertigo
Difficulty swallowing (dysphagia)
Tinnitus (ringing in the ears)
Hearing loss
Facial numbness or tingling
Weakness or clumsiness in the arms or legs
Sleep apnea symptoms (daytime sleepiness, snoring)
For suspected diagnosis: History suggestive of Chiari malformation but not yet diagnosed (e.g., some of the above symptoms).
Past Medical History:
Briefly summarize relevant past medical history, including:
Age at diagnosis of Chiari malformation (if applicable)
Type of Chiari malformation (if known)
Previous surgeries for Chiari malformation (if any)
Comorbid conditions that might contribute to symptoms (e.g., syringomyelia, hydrocephalus)
Social History:
Briefly inquire about potential risk factors (uncommon):
Family history of Chiari malformation
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess for:
Neurologic function (cranial nerve examination, motor and sensory function)
Signs of brainstem dysfunction (if present, may indicate severe Chiari):
Nystagmus (involuntary eye movements)
Dysarthria (slurred speech)
Facial weakness
Difficulty swallowing
Balance and coordination
Imaging Studies (if available):
Briefly summarize findings from recent brain and/or spinal cord MRI scans, including:
Degree of cerebellar tonsil herniation (descent below the foramen magnum)
Presence of syringomyelia (fluid-filled cavity in the spinal cord)
Signs of hydrocephalus (enlarged ventricles)
Assessment (A):
Chiari Malformation Type (if known):
Based on imaging studies, classify the type of Chiari malformation (I, II, III, or IV).
Severity of Chiari Malformation:
Integrate clinical presentation, imaging findings, and functional limitations to assess the severity of Chiari malformation.
Differential Diagnosis (if applicable):
Consider other causes of similar symptoms, such as:
Migraine headaches
Cervicogenic headaches (originating from the neck)
Inner ear problems
Multiple sclerosis
Plan (P):
Management:
The plan will depend on the severity of Chiari malformation and the presence of symptoms. Options may include:
Conservative Management:
Pain management medications for headaches and other symptoms.
Physical therapy to improve neck strength and posture.
Weight management (if overweight or obese)
Surgery:
Chiari decompression surgery may be considered for patients with severe symptoms or progressive neurologic decline. Discuss the risks and benefits of surgery with a neurosurgeon.
Monitoring:
Schedule regular follow-up visits to monitor for symptom progression and potential complications.
Consider repeat MRI scans at appropriate intervals based on the specific situation.
Patient Education:
Educate the patient about Chiari malformation, the specific type they have (if known), treatment options, and the importance of following the treatment plan.
Discuss potential long-term effects and the importance of seeking medical attention if symptoms worsen.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., neurosurgeon, neurologist)
Referral for additional testing (e.g., sleep study for suspected sleep apnea)
Importance of maintaining good posture and avoiding activities that may worsen symptoms (if applicable)
Support groups or resources for patients with Chiari malformation