Date:
Patient:
Admitting Physician:
Current Progress Note:
History of Present Illness:
Briefly describe the mechanism of injury (e.g., blunt trauma from motor vehicle accident, fall from height)
Onset and nature of symptoms (e.g., chest pain, shortness of breath, cough, hemoptysis – coughing up blood)
Duration of symptoms
Past medical history relevant to aortic injury (e.g., hypertension, atherosclerotic disease)
Physical Examination:
Summarize the pertinent physical examination findings, including:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
Signs of chest wall injury (e.g., tenderness, bruising, subcutaneous emphysema)
Cardiovascular exam (e.g., heart murmur, widened pulse pressure)
Respiratory exam (e.g., tachypnea – rapid breathing, decreased breath sounds)
Imaging Studies:
Describe the type of imaging studies performed to diagnose aortic injury (e.g., chest X-ray, CT angiography with contrast)
Summarize the findings, including:
Location and extent of the aortic injury (e.g., ascending aorta, descending aorta)
Presence of a contained rupture or free rupture
Evidence of mediastinal (chest cavity) widening or hematoma (blood collection)
Laboratory Studies:
List relevant laboratory tests performed (e.g., CBC, electrolytes, coagulation studies)
Briefly mention any abnormal findings (e.g., anemia from blood loss)
Assessment:
State the diagnosis of traumatic thoracic aortic injury based on clinical presentation and imaging studies.
Describe the severity of the injury (e.g., stable, unstable)
Discuss the risk of complications (e.g., hemothorax – blood in chest cavity, cardiac tamponade – compression of heart, aortic dissection – tear in aortic wall)
Plan:
Outline the treatment plan based on the severity of the injury and hemodynamic stability, including:
Close monitoring of vital signs and neurological status
Intravenous fluids and blood products (if needed)
Vasopressor support (if blood pressure is low)
Pain management
Medical management for stable injuries (e.g., blood pressure control)
Surgical intervention (e.g., open repair, endovascular stent graft) for unstable injuries
Consultation with specialists (e.g., cardiothoracic surgeon, vascular surgeon)
Follow-up:
Describe the planned follow-up for monitoring and evaluation (e.g., repeat imaging studies, serial vital signs)
Education:
Document patient education regarding the nature of the injury, treatment plan, potential complications, and activity restrictions.
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 traumatic thoracic aortic injury