Cardiothoracic Surgery Consult

Voltooide notitie

Patient Identification: adult patient presenting for evaluation of a newly identified ascending aortic enlargement, with a history of treated hypertension.

History of Present Illness:
An incidental enlargement was seen on chest imaging obtained for a persistent cough. The patient denies chest or back pain, fainting, or shortness of breath. No prior cardiac or thoracic procedures. The cough has improved.

Past Medical History:
- Hypertension

Medications:
- Lisinopril, dose not recorded

Allergies:
- No known drug allergies reported

Family History:
- No known aortic disease reported

Social History:
- No current tobacco use
- Lives with family; occupation not discussed

Physical Examination:
- HR: 74 beats/min, BP: 128/76 mmHg, T: 36.8 °C, RR: 16/min, O2 saturation: 98%
- Well appearing
- Regular rhythm, no murmur
- Lungs clear

Investigations:
- CT shows ascending aortic enlargement; measurement requires review of the full report
- Renal function within reference range

Assessment & Plan:
adult patient with ascending aortic enlargement referred for surgical evaluation.

1) Ascending aortic enlargement
- Review imaging and confirm dimensions before determining intervention threshold.
- Continue blood pressure management with primary clinician.
- Arrange echocardiography and multidisciplinary review.
- Discussed that management depends on confirmed measurements, growth, and overall risk. Follow up after imaging; seek urgent care for sudden severe chest or back pain, fainting, or new breathlessness.

Illustratieve casus met verzonnen patiëntgegevens. Dit is geen echt patiëntendossier en geen klinisch advies. Controleer elke notitie aan de hand van uw eigen consult.

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Herbruikbare sjabloonstructuur

Cardiothoracic Surgery Consult Note

[Date and time]

Patient Identification: [Patient name], [age], [gender], with a history of [relevant medical history], presenting with [chief complaint or reason for consult].

History of Present Illness:
[Detailed chronological description of presenting symptoms, relevant events, prior interventions, and current status. Include onset, duration, progression, associated symptoms, and any previous cardiac or thoracic procedures.]

Past Medical History:
(hyphenated list)
- [Relevant chronic illnesses, prior surgeries, cardiac or thoracic history]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug/other allergies, specify reaction]

Family History:
(hyphenated list)
- [Cardiac, thoracic, or other relevant conditions in family members]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Cardiovascular: findings]
- [Respiratory: findings]
- [Other relevant systems: findings]

Investigations:
(hyphenated list)
- [Relevant imaging (e.g., CXR, CT, echocardiogram) and laboratory results with units]
- [Other completed investigations]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary diagnosis or reason for surgical evaluation]

1) [Primary cardiac/thoracic diagnosis or surgical issue]
(hyphenated list)
- [Indication for surgery or intervention]
- [Preoperative optimization steps]
- [Additional investigations planned or ordered]
- [Consultations with other specialties]
- [Treatment plan (medical, surgical, or both)]
- [Counselling provided regarding risks, benefits, alternatives]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]