Can you provide a SOAP note for a 78-year-old male presenting for a follow-up wellness exam, with a chronic non-ruptured abdominal aortic aneurysm, abdominal bloating, and an in-office Saint Louis University Mental Status (SLUMS) test?

SOAP Note: 78-Year-Old Male Follow-Up Wellness Exam

SUBJECTIVE

Chief Complaint: Follow-up wellness examination

History of Present Illness:

• 78-year-old male presents for routine wellness follow-up
• Reports abdominal bloating (duration, severity, associated symptoms such as early satiety, nausea, vomiting, or weight loss should be documented)
• Known chronic non-ruptured abdominal aortic aneurysm (AAA)

Pertinent Medical History:

• Chronic AAA (document size if known, date of last imaging, smoking history)
• Smoking status (critical: "ever smoker" defined as ≥100 cigarettes lifetime) 1
• Hypertension status
• Cardiovascular risk factors

Review of Systems:

• Abdominal: Bloating as noted; assess for back pain, flank pain, or pulsatile abdominal mass sensation
• Constitutional: Fever, weight loss, or fatigue (rule out contained rupture or inflammatory AAA) 2
• Neurologic: Screen for cognitive concerns prompting SLUMS testing

OBJECTIVE

Vital Signs: Blood pressure (bilateral), heart rate, temperature, weight

Physical Examination:

• Cardiovascular: Regular rate and rhythm, peripheral pulses
• Abdominal:
  • Palpable pulsatile mass (location, size, tenderness)
  • Critical pitfall: Bloating with known AAA requires evaluation for duodenal compression between AAA and superior mesenteric artery/pancreas 3
  • Assess for tenderness suggesting contained rupture 2
  • Bowel sounds, distension pattern
• Neurologic: Mental status assessment

Cognitive Assessment:

• SLUMS Test Results: (Document raw score and interpretation based on education level)
  • High school education: 20-27 normal, 15-19 mild neurocognitive disorder, ≤14 dementia
  • Less than high school: 19-27 normal, 14-18 mild neurocognitive disorder, ≤13 dementia

Imaging/Studies:

• AAA surveillance imaging required based on aneurysm size 4, 5:
  • <3.0 cm: Not aneurysmal; rescreen in 5 years if 2.6-2.9 cm
  • 3.0-3.4 cm: Ultrasound every 3 years
  • 3.5-4.4 cm: Ultrasound every 12 months
  • 4.5-5.4 cm: Ultrasound every 6 months
  • ≥5.5 cm: Surgical referral indicated 1

ASSESSMENT

1. Chronic non-ruptured abdominal aortic aneurysm (specify size if known)

   • Surveillance interval depends on current size
   • Surgical threshold: ≥5.5 cm or rapid expansion (>0.5 cm/6 months) 1

2. Abdominal bloating

   • Differential diagnosis must include mechanical duodenal obstruction from AAA compression 3
   • Consider gastrointestinal causes if AAA-related compression excluded

3. Cognitive screening (based on SLUMS results)

   • Document specific cognitive domain concerns if abnormal

PLAN

AAA Management:

Immediate actions based on aneurysm size:

• If AAA <5.5 cm and stable: Continue surveillance ultrasound per size-based intervals above 4, 5
• If AAA ≥5.5 cm or rapidly expanding: Urgent vascular surgery referral 1
• Risk factor modification:
  • Smoking cessation if current smoker (highest priority for AAA progression)
  • Blood pressure control (target <140/90 mmHg)
  • Statin therapy for atherosclerotic disease

Bloating Evaluation:

Given AAA diagnosis, bloating requires specific workup:

• Order CT angiography (CTA) abdomen with IV contrast (rated 8/9 appropriateness) 4 to:
  • Assess AAA size accurately
  • Evaluate for duodenal compression between AAA and superior mesenteric artery 3
  • Rule out contained rupture if any concerning features present 2
• If CTA shows duodenal compression: Gastroenterology and vascular surgery co-management
• If CTA negative for mechanical obstruction: Pursue standard gastrointestinal bloating workup

Cognitive Assessment Follow-up:

• If SLUMS abnormal: Refer to neurology/geriatrics for comprehensive evaluation
• If normal: Routine age-appropriate cognitive monitoring

Follow-up:

• Return visit timing based on AAA size and imaging results
• Critical safety net: Educate patient on AAA rupture symptoms (sudden severe abdominal/back pain, syncope) requiring immediate emergency evaluation 1

Common pitfall to avoid: Do not dismiss bloating as benign gastrointestinal complaint in AAA patients without imaging evaluation for mechanical compression 3.