Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for presentation, typically severe abdominal pain:
Sudden onset, severe, and persistent abdominal pain (characteristic but not always present)
May be described as cramping, colicky, or dull aching
Often located in the periumbilical region (around the navel)
May radiate to the back or lower abdomen
History of Present Illness:
Onset and duration of pain
Severity of pain (graded on a scale)
Associated symptoms:
Nausea and vomiting
Diarrhea (may be bloody)
Abdominal distention
Fever (may be present in later stages)
Past medical history (vascular disease, diabetes, smoking, hypertension)
Risk factors for atherosclerosis
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
General examination (appearance of illness, signs of dehydration)
Abdominal examination:
Distention
Tenderness to palpation (may be diffuse or localized)
Decreased bowel sounds (late sign)
Guarding or rigidity (late sign)
Rectal examination: May reveal blood in stool.
Laboratory Findings:
Complete blood count (CBC): May show leukocytosis (high white blood cell count) in advanced stages.
Basic metabolic panel (BMP): May show electrolyte imbalances (acidosis) due to tissue ischemia.
Lactase dehydrogenase (LDH): May be elevated in advanced stages.
Coagulation studies (PT, INR, aPTT): Assessed for bleeding risk before potential procedures.
Imaging Studies:
Abdominal X-ray: May show signs of bowel distention or ileus (paralyzed bowel).
Abdominal CT scan with angiography: Preferred imaging study to visualize arterial blockages and assess bowel viability.
Doppler ultrasound (may be used initially): Can assess blood flow in the mesenteric arteries, but less definitive than CT angiography.
Assessment:
Summarize the findings and diagnose acute mesenteric ischemia based on clinical presentation, physical examination, and imaging studies.
Describe the likely cause of the arterial blockage (atherosclerosis, embolus, mesenteric venous thrombosis).
Stage the severity of ischemia using a scoring system (e.g., Garcia classification).
Consider the potential complications of AMI (bowel infarction, perforation, peritonitis, sepsis).
Plan:
The goal of treatment is to restore blood flow to the intestines as quickly as possible to prevent bowel infarction and tissue death. This may involve:
Thrombolytic therapy: Medications to dissolve blood clots (time-dependent treatment).
Endovascular intervention (angioplasty and stenting): Minimally invasive procedure to open blocked arteries.
Open surgical bypass grafting: Uses a graft vessel to bypass the blockage. In severe cases with bowel infarction, bowel resection may be necessary.
General Measures:
Intravenous fluids for resuscitation
Nasogastric tube placement to decompress the stomach
Broad-spectrum antibiotics to prevent infection (if bowel infarction is suspected)
Pain management
Specialty Consultations:
Vascular surgery
Gastroenterology (if bowel resection is needed)
Progress Notes:
Document daily assessments including vital signs, pain level, abdominal exam findings, bowel sounds, and urine output.
Note any changes in laboratory results.
Update the plan as needed based on the patient’s progress, response to treatment, and development of complications.
Discharge Instructions (for patients with revascularized intestines):
Smoking cessation counseling (if applicable)
Medical management for risk factors (e.g., diabetes, hypertension)
Follow-up appointments with a vascular surgeon
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Early diagnosis and intervention are crucial to minimize bowel tissue death and improve patient outcomes.