Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Age at diagnosis of coarctation of aorta (CoA):
Presenting symptoms (if any):
Chest pain (location, character, duration)
Dyspnea (on exertion or at rest)
Leg weakness or claudication
High blood pressure (limited to upper extremities)
Signs of heart failure (fatigue, edema)
Developmental delay (in children)
Current symptoms:
Functional limitations due to CoA:
Medical history since CoA diagnosis (interventions, complications)
II. Past Medical History:
Risk factors for CoA (congenital syndromes, bicuspid aortic valve)
Other relevant medical conditions (hypertension, heart failure)
III. Social History:
Activity level: (restricted due to CoA, limitations)
Family history of CoA or congenital heart disease
IV. Physical Exam:
Vital signs: (BP in upper and lower extremities, HR, RR)
Cardiovascular exam:
Blood pressure differentials (upper vs. lower extremities)
Femoral pulses (weak or delayed compared to radial pulses)
Murmurs (systolic murmur over back or left upper sternal border)
Other findings suggestive of heart failure (jugular venous distention, peripheral edema)
V. Imaging Studies (if available):
Chest X-ray: (cardiomegaly, signs of left ventricular hypertrophy)
Echocardiogram:
Confirmation of CoA location and severity
Left ventricular function
Aortic arch anatomy
Cardiac MRI/Angiography (if performed):
Detailed evaluation of CoA anatomy
Assessment for potential complications
VI. Assessment:
Coarctation of aorta (native or repaired, severity)
Blood pressure control (controlled, uncontrolled)
Functional status (limited by CoA, limitations)
Risk of complications (heart failure, aneurysm formation)
VII. Plan:
Management strategy:
Medical management (antihypertensives)
Surgical intervention (type of procedure planned/performed, anticipated timing)
Endovascular intervention (if applicable)
Monitoring plan: (clinical follow-up, imaging studies)
Education: Patient education on CoA, treatment plan, and potential risks/complications.
VIII. Notes:
Include any additional relevant information, such as laboratory studies or specific medications used.
IX. Resources:
Consider providing patient education materials on coarctation of the aorta from reputable sources (e.g., American Heart Association).