Date:
Patient:
MRN:
Clincian: (Vascular Surgeon, Interventional Radiologist, Hepatologist)
Reason for Visit:
Follow-up for hepatic artery aneurysm
Review of imaging studies (ultrasound, CT angiography, angiography)
Assessment for symptoms and complications
Discussion of management plan
History of Present Illness:
Briefly describe the patient’s current status:
Presence or absence of abdominal pain, nausea, vomiting (may occur with rupture)
Any new or worsening symptoms since last visit
Unexplained weight loss (potential symptom in some cases)
Past Medical History:
Underlying medical conditions (atherosclerosis, connective tissue diseases)
Previous surgeries or hospitalizations (prior infections, trauma to the liver)
Risk factors for atherosclerosis (hypertension, hyperlipidemia, smoking)
Family History:
Family history of atherosclerosis or connective tissue diseases
Social History:
Smoking history (significant risk factor)
Physical Exam:
Vital Signs: May be normal unless complications arise (rupture leading to hemorrhage).
Abdominal exam:
Normal exam findings are common.
Consider mentioning a palpable pulsatile mass in the right upper quadrant if present.
Consider mentioning signs of blood loss (hypotension, tachycardia) if rupture is suspected.
Labs:
Routine laboratory tests are not diagnostic for hepatic artery aneurysm but may be performed to assess overall health.
Consider mentioning liver function tests (LFTs) if performed.
Consider mentioning a complete blood count (CBC) if rupture is suspected (anemia due to blood loss).
Imaging:
Ultrasound: May identify a mass in the liver but may not definitively diagnose an aneurysm.
CT angiography or angiography: These imaging studies are crucial for diagnosing a hepatic artery aneurysm and determining its size, location, and involvement of other vessels.
Assessment:
Summarize the diagnosis of hepatic artery aneurysm based on imaging studies.
Mention the size and location of the aneurysm.
Discuss the risk of complications (rupture, thrombosis) based on the size and characteristics of the aneurysm.
Plan:
Outline the management plan based on the size, growth rate, and risk of complications:
Observation: For small (<3cm), asymptomatic aneurysms with slow growth rates, observation with serial imaging (CT angiography at regular intervals) may be recommended.
Endovascular intervention: Minimally invasive procedure using a catheter to place a stent graft to exclude the aneurysm from blood flow.
Open surgical repair: Traditional surgery to remove the aneurysm and reconstruct the hepatic artery. This may be preferred for larger or symptomatic aneurysms.
Consider mentioning the need for ongoing monitoring with imaging studies at specified intervals.
Education:
Document any education provided to the patient regarding:
The nature of hepatic artery aneurysm and its potential complications
The importance of adhering to the recommended follow-up plan with imaging studies
Lifestyle modifications to reduce the risk of complications (smoking cessation, healthy diet, weight management)
Warning signs and symptoms of potential complications (acute abdominal pain, nausea, vomiting)
The benefits and risks of endovascular intervention or surgical repair if applicable
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 follow-up imaging, potential complications, or the need for surgery.
Address the potential anxiety associated with a vascular condition and offer support or referral for mental health services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a vascular surgeon, interventional radiologist, or hepatologist for diagnosis, treatment recommendations, and prognosis.