Date:
Patient:
MRN:
Clincian: (Vascular Surgeon, Gastroenterologist)
Reason for Visit:
Follow-up for gastric artery aneurysm (GAA)
Evaluation of symptoms (if applicable)
Review of imaging results
Treatment plan discussion
History of Present Illness:
Briefly describe the patient’s current status:
Time since diagnosis of GAA
Presence and severity of any symptoms (abdominal pain, nausea, vomiting, GI bleeding) – symptoms may be vague or absent
Change in symptoms since initial diagnosis
Past Medical History:
Underlying conditions that may increase risk (atherosclerosis, hypertension)
History of abdominal surgeries (may increase risk of iatrogenic GAA)
Other medical conditions (important for anesthesia considerations during surgery)
Family History:
Family history of aneurysms (may suggest a genetic predisposition)
Social History:
Smoking history (significant risk factor for atherosclerosis)
Physical Exam:
Vital Signs: May be normal unless there are complications (rupture, bleeding).
Abdominal: Palpation for tenderness or pulsatile mass (uncommon finding).
Labs:
Labs are not specific for GAA diagnosis, but may be ordered to assess overall health:
Complete Blood Count (CBC) – to check for anemia if bleeding is suspected.
Basic Metabolic Panel (BMP) – to assess kidney function (important for contrast used in imaging).
Coagulation studies – may be checked before surgery.
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Previous imaging studies: Briefly describe the findings of the imaging study (abdominal CT scan with angiography or digital subtraction angiography (DSA)) that identified the GAA. This should include:
Location and size of the aneurysm
Current imaging studies: May be repeated depending on the clinical presentation:
If asymptomatic with a small GAA (< 1.5 cm), consider mentioning the option for observation with serial imaging to monitor for growth.
If symptoms are present, worsening, or the aneurysm is large (> 1.5 cm), repeat imaging may be indicated to assess for changes.
Assessment:
Summarize the current status based on symptoms, physical exam, and imaging:
Confirmation of GAA diagnosis based on imaging.
Size and location of the aneurysm.
Presence and severity of symptoms (if any).
Risk of complications (rupture, bleeding).
Plan:
Outline the management plan based on the assessment:
Observation: For asymptomatic patients with small GAA (< 1.5 cm), observation with serial imaging (CT scan with angiography) at regular intervals (usually 3-6 months) may be recommended.
Endovascular repair: Minimally invasive procedure using catheters to place a stent graft to exclude the aneurysm from blood flow. May be preferred for some patients.
Open surgical repair: Traditional surgery involving laparotomy (abdominal incision) to remove the aneurysm and reconstruct the artery.
Referral to a vascular surgeon for further evaluation and treatment recommendations.
Education:
Document any education provided to the patient regarding:
The nature of GAA, its formation, and potential complications
The importance of risk factor modification (smoking cessation, blood pressure control)
The rationale for observation, endovascular repair, or open surgical repair depending on the situation
The importance of following up with a vascular surgeon as recommended
Prognosis:
Briefly discuss the prognosis. Small asymptomatic GAA may be managed with observation.
Larger aneurysms or those with symptoms carry a higher risk of complications (rupture, bleeding) and require intervention.
Early diagnosis and treatment with endovascular repair or open surgery can improve outcomes and reduce the risk of complications.
Notes:
Include any additional relevant information not covered above, such as the patient's understanding of the diagnosis and treatment plan, and any concerns they may have about the risks and benefits of different treatment options.
Consider mentioning the importance of seeking immediate medical attention if they experience severe abdominal pain, nausea, or vomiting, which could suggest complications.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis, treatment recommendations, and prognosis.