Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CLTI, evaluation of worsening symptoms, wound care, or revascularization planning.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of leg symptoms:
Pain (location, character, duration, severity at rest and with activity – claudication)
Numbness, coldness, or paresthesias in the affected limb
Changes in skin color (pallor, rubor, cyanosis)
Presence of wounds or ulcers (location, size, drainage, duration)
Gangrene (tissue death) – a serious complication of CLTI
Functional limitations due to pain or claudication
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying vascular disease (atherosclerosis)
Risk factors for atherosclerosis (diabetes, hypertension, hyperlipidemia, smoking)
History of previous interventions for CLTI (angioplasty, bypass surgery)
Presence of co-morbidities (e.g., coronary artery disease, cerebrovascular disease)
Social History:
Inquire about smoking history (smoking cessation is crucial for CLTI management).
Ask about occupation and impact of symptoms on work or daily activities.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure (measure blood pressure in both arms to assess for aortoiliac disease).
Physical Exam:
Assess the affected leg for:
Skin color, temperature, and hair distribution
Presence of pulses (dorsalis pedis and posterior tibial) – absent or weak pulses suggest severe ischemia
Bruits (abnormal sounds over arteries) – may indicate stenosis
Signs of infection (erythema, induration, purulence) in wounds
Gangrene (demarcation of dead tissue)
Non-invasive Vascular Testing (Ankle-Brachial Index (ABI)):
Assess ABI by comparing blood pressure in the leg to that in the arm. A low ABI (<0.7) indicates significant arterial insufficiency. Assessment (A): Severity of CLTI: Classify the severity of CLTI based on symptoms, physical exam findings, and ABI (Rutherford classification system). Wound Status: Describe the location, size, depth, and drainage characteristics of any wounds. Assess for signs of infection (cellulitis). Risk of Limb Loss: Evaluate the risk of limb amputation based on the severity of ischemia, wound status, and presence of gangrene. Plan (P): Wound Care: Develop a wound care plan based on the wound characteristics and presence of infection. This may include: Debridement of necrotic tissue Dressings to promote healing and manage drainage Offloading techniques (special shoes or casts) to reduce pressure on wounds Revascularization Options (if indicated): Consider potential revascularization procedures to improve blood flow to the affected limb, such as: Percutaneous intervention (angioplasty with stenting) Bypass surgery Medical Management: Optimize medical management of underlying conditions (diabetes, hypertension, hyperlipidemia) to slow disease progression. Consider medications to improve blood flow (cilostazol) or manage pain. Smoking Cessation: Strongly encourage smoking cessation, which is critical for improving outcomes in CLTI. Referral (if indicated): Consider referral to a vascular surgeon for evaluation of revascularization options or a podiatrist for specialized wound care. Follow-up: Schedule frequent follow-up visits to monitor wound healing, assess response to treatment, and evaluate for signs of infection or worsening ischemia. Define the frequency of follow-up based on the severity of CLTI, wound status, and presence of complications. Patient Education: Educate the patient about CLTI, its causes, risk factors, and the importance of treatment adherence. Provide information on wound care practices and signs of infection. Discuss the importance of smoking cessation and healthy lifestyle modifications. Explain the risks and benefits of potential revascularization procedures (if applicable). Offer resources for support groups or educational materials on managing CLTI.