Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concerns, such as sudden, tearing chest pain (may radiate to back), dyspnea (shortness of breath), cough, sweating, or syncope (fainting).
History of Present Illness:
Onset, duration, and severity of symptoms.
Characteristics of chest pain (sudden, tearing, radiating).
Associated symptoms (e.g., cough, dyspnea, sweating, neurological symptoms like weakness or numbness).
Risk factors for aortic dissection (e.g., hypertension, atherosclerosis, smoking history, connective tissue diseases like Marfan syndrome).
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 dissection or connective tissue diseases.
Physical Exam:
Vital signs (may be unstable with elevated blood pressure, tachycardia, or hypotension).
General examination (assess for signs of distress, sweating, pallor).
Cardiovascular examination:
Blood pressure asymmetry in different limbs (suggestive but not diagnostic).
Pulse deficits (weak or absent pulses in certain arteries depending on dissection location).
Auscultation for bruits over the aorta.
Respiratory examination (assess for signs of respiratory distress).
Neurological examination (if neurological symptoms are present).
**Diagnostic Tests (urgent):
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 aortic dissection, assess involvement of aortic branches, and identify complications.
Echocardiogram (optional): May be used to assess for aortic valve involvement or complications like aortic insufficiency.
Assessment:
High clinical suspicion of thoracic aortic dissection based on history and physical exam findings.
Confirmation of diagnosis with urgent CT angiogram.
Type of dissection (Stanford A vs. Stanford B classification).
Involvement of aortic branches and presence of complications (e.g., organ ischemia, pericardial effusion, aortic insufficiency).
Hemodynamic stability (stable vs. unstable).
Plan:
Urgent Management: Aims to stabilize the patient and prevent further dissection. This may involve:
Aggressive blood pressure control with medications.
Pain management with medications.
Inotropic support for hemodynamic instability.
Definitive Treatment: Depending on the type of dissection and hemodynamic status, consider:
Open Surgical Repair: Traditional surgery with repair or replacement of the affected aortic segment, often for Stanford A dissections and unstable Stanford B dissections.
Endovascular Aortic Repair (EVAR): Minimally invasive procedure for specific anatomic presentations of Stanford B dissections.
Follow-up: Schedule close follow-up with imaging studies to monitor for complications and ensure adequate repair.
Patient Education: Educate the patient about thoracic aortic dissection, risk factors, treatment options, potential complications, and the importance of lifestyle modifications and follow-up care.
Additional Notes:
Document the time of symptom onset to facilitate timely intervention.
Note any hemodynamic instability and need for immediate resuscitation.
Consider referral to a cardiothoracic surgeon or vascular surgeon for urgent evaluation and potential surgical intervention.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. Prompt diagnosis and treatment are crucial for improved outcomes in thoracic aortic dissection