Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CVI, evaluation of symptoms, leg exam, and management plan.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of leg symptoms:
Duration of symptoms (pain, heaviness, fatigue)
Worsening of symptoms with prolonged standing or sitting and improvement with leg elevation
Skin changes (itching, discoloration, eczema)
Leg swelling (edema)
History of ulcers (open sores)
Past Medical History:
Briefly summarize relevant past medical history, including:
Risk factors for CVI (deep vein thrombosis (DVT), prolonged immobilization, obesity, pregnancy)
History of previous DVT or PE (pulmonary embolism)
Underlying medical conditions (e.g., heart failure, peripheral arterial disease)
Social History:
Inquire about occupation (prolonged standing or sitting can worsen symptoms).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Leg Exam:
Assess for:
Edema (location, severity)
Skin changes (varicose veins, pigmentation, eczema)
Ulcers (location, size, depth)
Ankle reflexes (may be diminished in severe CVI)
Doppler Ultrasound (if performed):
Briefly describe Doppler ultrasound findings, which can assess blood flow patterns and identify venous insufficiency.
Assessment (A):
Severity of CVI:
Classify the severity of CVI based on clinical findings using a scoring system (e.g., CEAP classification).
Presence of Complications:
Evaluate for potential complications of CVI (e.g., cellulitis, lipodermatosclerosis).
Plan (P):
Lifestyle Modifications:
Recommend lifestyle changes to improve venous return:
Elevation of legs when resting
Compression stockings to improve circulation
Regular exercise (walking, swimming)
Weight management (if overweight or obese)
Skin Care:
Advise on proper skin care to prevent itching and infection:
Moisturize dry skin
Avoid scratching
Treat eczema if present
Medications:
Consider medications for specific symptoms:
Diuretics (for leg swelling)
Antibiotics (for cellulitis)
Venous tonics (limited role)
Compression Therapy:
Prescribe appropriate compression stockings to improve circulation and reduce swelling.
Referral (if indicated):
Consider referral to a vascular surgeon for patients with severe CVI, recurrent ulcers, or those who fail to respond to conservative treatment.
Follow-up:
Schedule follow-up visits to monitor symptoms, leg exam findings, and response to treatment.
Define the frequency of follow-up based on disease severity, presence of complications, and adherence to recommendations.
Patient Education:
Educate the patient about CVI, its causes, risk factors, and the importance of self-care measures.
Discuss the benefits of lifestyle modifications, compression therapy, and proper skin care.
Explain the signs and symptoms of complications to watch for (e.g., cellulitis) and the importance of seeking prompt medical attention.
Offer resources for support groups or educational materials on managing CVI.