Patient: [Patient Name]
Date: [Date of Encounter]
I. History of Present Illness:
Onset and duration of symptoms:
Abdominal pain (location, character, severity)
Change in bowel habits (diarrhea, constipation, bloody stools)
Rectal bleeding
Nausea and vomiting
Risk factors for colonic ischemia (select all that apply):
Age > 65 years
Atherosclerotic vascular disease (coronary artery disease, peripheral artery disease)
Low blood pressure (hypotension)
Arrhythmias
Cardiac surgery or procedures
Vasculitis
Hypercoagulable state
Medications (vasoconstrictors)
Previous abdominal surgeries: (yes/no) – If yes, specify details (type of surgery, potential impact on blood flow)
II. Past Medical History:
Underlying medical conditions (diabetes, hypertension, chronic kidney disease)
III. Social History:
Smoking history: (current smoker, former smoker, never smoker)
Medications: List all current medications (including over-the-counter)
IV. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Abdominal exam:
Distention
Tenderness to palpation
Guarding
Bowel sounds (hypoactive or absent)
Rectal exam: (blood on stool)
V. Assessment:
Suspected colonic ischemia (acute or chronic)
Severity of ischemia (based on clinical presentation and diagnostics)
Possible segment of colon involved (right, left, transcolonic)
Differential diagnoses (constipation, inflammatory bowel disease, diverticulitis)
VI. Diagnostic Studies:
Laboratory tests:
Complete blood count (CBC) with differential
Electrolytes
Renal function tests (BUN, creatinine)
Coagulation studies (PT, PTT)
Lactate levels (elevated may indicate ischemia)
Imaging studies (consider urgency based on suspicion):
Abdominal X-ray: (may show signs of bowel obstruction)
CT scan with angiography: (gold standard for diagnosis, assesses blood flow)
Colonoscopy (with caution, may worsen ischemia): visualize mucosal changes
VII. Plan:
Treatment plan depends on severity and segment involved:
Conservative management (fluid resuscitation, bowel rest, broad-spectrum antibiotics)
Endovascular intervention (angioplasty, stenting) to improve blood flow
Surgical intervention (colectomy) to remove non-viable bowel segment
Supportive care: (pain management, nutritional support)
Follow-up plan: (clinical monitoring, repeat imaging if indicated)
VIII. Notes:
Include any additional relevant information, such as response to treatment, potential complications (perforation, sepsis), and prognosis.
IX. Resources:
Consider providing patient education materials on colonic ischemia from reputable sources (e.g., National Institute of Diabetes and Digestive and Kidney Diseases).