Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, typically severe pain, swelling, and paresthesias (tingling) in the affected extremity.
History of Present Illness:
Onset and duration of symptoms
Mechanism of injury (trauma, tight cast, prolonged compression)
Character of pain (severe, unremitting, out of proportion to injury)
Associated symptoms (swelling, weakness, paresthesias, paralysis)
Past medical history (comorbidities, previous surgeries)
Medications (anticoagulants)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
General examination (appearance of illness)
Examination of the affected extremity:
Pain with palpation
Tense swelling
Skin tightness, pallor, or coolness (later signs)
Weakness or paralysis (late signs)
Compartment pressure measurements (using a pressure transducer) [This is a crucial element for diagnosing ACS]
Laboratory Findings:
Complete blood count (CBC) – may show elevated white blood cell count (WBC) if there’s associated infection
Coagulation studies (PT, PTT) – if considering fasciotomy (surgical decompression)
Imaging Studies:
X-rays – may show underlying fractures or dislocations, but not diagnostic for ACS
Angiography (may be considered in specific cases)
Assessment:
Summarize the findings, including compartment pressure measurements.
Clearly state the diagnosis of ACS based on clinical presentation and pressure measurements.
Specify the affected compartment(s).
Plan:
Urgent Surgical Management (cornerstone of treatment):
Fasciotomy (surgical decompression of the involved compartment(s))
The specific type of fasciotomy will depend on the affected compartment(s).
Supportive Measures:
Intravenous fluids
Pain management
Antibiotic prophylaxis (if indicated)
Elevation of the affected extremity
Progress Notes:
Document hourly assessments of the affected extremity, including pain level, swelling, skin changes, capillary refill, compartment pressures (if continued monitoring is needed), and neurovascular status (motor and sensory function).
Note any laboratory or imaging results obtained during the hospitalization.
Update the plan as needed based on the patient’s response to treatment.
Discharge:
Summarize the patient’s hospital course and current condition.
Detail the surgical procedure performed and post-operative care.
Discharge instructions including wound care, physical therapy recommendations, follow-up appointments, and potential complications to watch for.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment.