Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Lower extremity injury with suspected/confirmed arterial involvement
History of Present Illness:
Describe the mechanism of injury (blunt trauma – e.g., motor vehicle accident, fall from height; penetrating trauma – e.g., gunshot wound, stab wound).
Include the time of injury and any immediate symptoms (pain, swelling, coolness, numbness, tingling, weakness, paralysis).
Mention pre-hospital care received if applicable.
Past Medical History:
Include any relevant past medical history, such as:
Peripheral arterial disease (PAD) or other vascular conditions
Pre-existing medical conditions (e.g., diabetes, hypertension) that can worsen arterial injury outcomes.
History of smoking (significant risk factor for vascular disease).
Medications:
List all current medications, including anticoagulants or antiplatelet medications.
Allergies:
Mention any allergies to medications, contrast media (important for imaging studies).
Social History:
Inquire about smoking history and other lifestyle habits that can impact vascular health.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure (measure blood pressure in both legs to assess for asymmetry).
Affected extremity:
Inspect for signs of bleeding, swelling, bruising, deformity.
Palpate for distal pulses (dorsalis pedis and posterior tibial) – compare bilaterally.
Assess for skin temperature and color changes (coolness, pallor).
Evaluate capillary refill (press on the nail bed and assess how quickly pink color returns).
Test for motor and sensory function.
Evaluate the uninjured extremity for comparison of pulses and overall circulation.
Imaging Studies:
Angiography: The gold standard for definitive diagnosis and localization of arterial injury.
Doppler ultrasound: May be used initially to assess blood flow and identify potential areas of injury, but may not be definitive for all cases.
Assessment:
Diagnosis: State “suspected lower extremity arterial injury” or “confirmed lower extremity arterial injury” based on clinical findings and imaging studies.
Anatomical location of injury: Describe the location of the arterial injury (e.g., popliteal artery occlusion).
Limb viability: Assess the viability of the affected limb based on circulation, tissue perfusion, and presence of gangrene.
Risk stratification: Briefly describe the perceived risk of limb loss based on the severity of injury, time elapsed since injury, and overall health status.
Plan:
Urgent revascularization: This is the priority for most arterial injuries to restore blood flow and salvage the limb. This may involve:
Endovascular intervention (angioplasty with stent placement) for suitable injuries.
Open surgical repair for more complex injuries or those not amenable to endovascular intervention.
Antibiotics (prophylactic): May be administered to prevent infection.
Pain management: Medications to address pain associated with the injury.
Tetanus prophylaxis: Update tetanus vaccination status if needed.
Vascular consultation: Prompt consultation with a vascular surgeon is crucial for definitive management decisions.
Serial vascular exams: Close monitoring of the affected extremity with frequent pulse checks, skin temperature assessments, and capillary refill testing.
Follow-up:
Depending on the severity of injury and treatment approach, the patient may require ongoing hospitalization for monitoring and management.
Schedule follow-up clinic visits with the vascular surgeon to assess healing progress and long-term management of any residual vascular issues.
Consider referral for physical or occupational therapy if needed for limb function rehabilitation.