Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be:
Initial evaluation for suspected abdominal vascular injury (AVI) following trauma.
Follow-up visit for a patient with confirmed AVI.
Monitoring response to treatment for AVI.
Post-operative management following intervention for AVI.
History of Present Illness (HPI)
Focus on the mechanism of injury (e.g., blunt trauma, penetrating trauma).
Describe any symptoms suggestive of AVI, including:
Abdominal pain (onset, severity, character, location)
Abdominal distention
Nausea and vomiting
Rectal bleeding
Hematuria (blood in urine)
Hypotension (low blood pressure)
Tachycardia (fast heart rate)
Mention the duration, progression, and any aggravating or alleviating factors for the symptoms.
Past Medical History (PMHx)
Briefly mention any relevant past medical history, such as:
Pre-existing vascular disease
Bleeding disorders
Co-morbidities that may affect management (e.g., coronary artery disease)
Social History (SHx)
Include relevant social history, such as:
Anticoagulant use
Smoking history
Medications
List all current medications the patient is taking, with particular attention to anticoagulants.
Allergies
Document any known allergies, especially to medications.
Physical Examination
General: Assess overall health, appearance of distress, and signs of hypovolemia (decreased blood volume).
Vital Signs: Document blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
Abdomen:
Inspect for distention, discoloration, or pulsatile masses.
Palpate for tenderness, guarding (involuntary muscle tensing), and assess for dullness to percussion (indicates fluid accumulation).
Assess for bruits (abnormal sounds) over the abdomen.
Rectal Examination: May reveal blood on digital exam.
Laboratory Tests
Mention relevant laboratory tests obtained and their results, including:
Complete blood count (CBC) – looking for anemia (low red blood cell count)
Coagulation studies (PT, PTT) – assess bleeding risk
Blood type and Rh factor – for potential blood transfusion
Blood gas analysis – assess oxygenation and acid-base balance
Imaging Studies
Mention any imaging studies performed and their results, focusing on vascular imaging to identify and localize the injury:
Abdominal X-ray (may show signs of bowel injury)
Abdominal ultrasound (may identify free fluid in the abdomen)
CT angiogram (most definitive study for diagnosing AVI)
Assessment
Summarize the key findings from the history, physical examination, labs, and imaging.
State whether AVI is confirmed, suspected, or ruled out.
If confirmed, describe the location and type of vascular injury (e.g., arterial transection, venous laceration).
Estimate the severity of the injury based on clinical presentation and imaging findings.
Plan
Outline the next steps in the patient’s management. This may include:
Initial Resuscitation:
Address fluid resuscitation and blood transfusion as needed to maintain blood pressure and tissue perfusion.
Vascular Intervention:
Urgent surgical intervention (e.g., laparotomy, endovascular repair) is typically necessary to repair the injured vessel and control bleeding.
Specify the planned surgical or endovascular procedure.
Management of Underlying Injury:
Address any associated injuries (e.g., bowel perforation) medically or surgically.
Blood Products: May require ongoing blood product transfusions to replace blood loss.
Antibiotics: Prophylactic antibiotics to prevent surgical site infection.
Vasopressors: If indicated to maintain blood pressure in the setting of aggressive fluid resuscitation.
Serial Monitoring: Close monitoring of vital signs, urine output, and serial hemoglobin levels to assess for ongoing blood loss.
Prognosis: Briefly discuss the prognosis which can be guarded depending on the severity of the injury, delays in treatment, and presence of complications.
Additional Considerations