Cardiothoracic Surgery Consult

Färdig anteckning

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.

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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]