Subjective:
Date of visit
Reason for visit (incidental finding, symptoms)
Current symptoms (if any):
Migraines (particularly with aura)
Shortness of breath (especially on exertion)
History of stroke or transient ischemic attack (TIA)
Unexplained fatigue
Past medical history (relevant conditions like heart disease, deep vein thrombosis)
Family history (congenital heart defects)
Objective:
Vital signs (blood pressure, oxygen saturation)
Physical exam (focusing on normal findings, no murmurs usually)
May include tests done previously (depending on presentation):
Echocardiogram (transthoracic or transesophageal) with bubble study (if needed)
Right heart catheterization (rarely)
Assessment:
Patent foramen ovale (PFO)
Size of PFO (small, medium, large)
Presence of other septal abnormalities
Consider differential diagnoses based on symptoms (e.g., migraine with aura, pulmonary embolism)
Plan:
Management depends on symptoms and risk factors:
Observation (most common)
Medications (blood thinners if high stroke risk)
PFO closure procedure (catheter-based or surgical) considered in specific cases
Recommend lifestyle modifications (healthy diet, exercise, weight management)
Schedule for follow-up visits based on individual needs
Follow-up:
Schedule next appointment in X weeks/months for monitoring
Discuss need for repeat imaging (if indicated)
Note: This is a template and may be adjusted based on the patient’s presentation.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of PFO