Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concerns, such as chest pain (sudden, tearing, radiating to back), cough, dyspnea (shortness of breath), hoarseness, or new onset back pain. Note if asymptomatic.
History of Present Illness:
Onset, duration, and severity of symptoms.
Characteristics of chest pain (if present).
Associated symptoms (e.g., cough, dyspnea, hoarseness, sweating).
Risk factors for aortic aneurysm (e.g., hypertension, atherosclerosis, smoking history, family history).
Prior surgeries or interventions for aortic aneurysm.
Past Medical History:
Cardiovascular history (e.g., hypertension, coronary artery disease, previous cardiac surgeries).
Pulmonary history (e.g., COPD, asthma).
Connective tissue diseases (e.g., Marfan syndrome, Ehlers-Danlos syndrome).
Other relevant medical conditions.
Medications:
List of current medications, including antihypertensives, cholesterol medications, and blood thinners.
Social History:
Smoking history (significant risk factor).
Family history of aortic aneurysm.
Physical Exam:
Vital signs (elevated blood pressure may be present).
General examination (assess for signs of distress, sweating).
Cardiovascular examination:
Palpation for pulsatile masses on chest wall.
Auscultation for bruits over the aorta.
Respiratory examination (assess for signs of respiratory distress).
**Diagnostic Tests (as indicated):
Chest X-ray: May show widening of the mediastinum (suggestive but not diagnostic).
CT angiogram of the chest and abdomen: Definitive test to visualize the aorta, measure aneurysm size, and assess for involvement of other branches.
Echocardiogram (optional): May be used to assess for aortic valve disease or complications like aortic insufficiency.
Assessment:
Clinical suspicion of thoracic aortic aneurysm based on history and physical exam findings.
Confirmation of diagnosis with CT angiogram.
Aneurysm size and location (ascending aorta, aortic arch, descending aorta).
Rate of aneurysm growth based on previous imaging (if available).
Presence of complications (e.g., aortic dissection, impending rupture).
Risk stratification based on size, symptoms, and co-morbidities.
Plan:
Treatment: Discuss treatment options based on aneurysm size, symptoms, and risk factors. This may include:
Medical Management: Lifestyle modifications (smoking cessation, blood pressure control) for small asymptomatic aneurysms.
Endovascular Aortic Repair (EVAR): Minimally invasive procedure for certain types of aneurysms.
Open Surgical Repair: Traditional surgery with replacement of the affected aortic segment.
Pain Management: Address pain symptoms with medications.
Follow-up: Schedule regular follow-up appointments for monitoring aneurysm size with imaging studies and clinical evaluation. The frequency of follow-up depends on the size and growth rate of the aneurysm.
Patient Education: Educate the patient about thoracic aortic aneurysm, risk factors, treatment options, potential complications, and the importance of lifestyle modifications and follow-up care.
Additional Notes:
Document any additional relevant information not covered above (e.g., referral to a cardiothoracic surgeon or vascular surgeon).
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. It is important to follow established guidelines for the diagnosis, risk stratification, treatment, and management of thoracic aortic aneurysm