Subjective
Date of visit
Reason for visit (initial presentation, follow-up)
History of present illness:
Claudication (pain, cramping, or tightness in the legs brought on by activity and relieved with rest) – specify location (calf, buttocks, thighs) and typical walking distance before symptoms start (claudication distance)
Rest pain (pain in the legs even at rest, worse at night, may improve with hanging)
Non-healing wounds or ulcers on the toes or feet
Gangrene (tissue death) in severe cases
Risk factors for PAD (smoking, diabetes, hypertension, hyperlipidemia)
Past medical history (relevant conditions, previous surgeries)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General (signs of poor circulation)
Peripheral vascular examination:
Palpation of dorsalis pedis and posterior tibial pulses (absent or weak pulses suggest PAD)
Ankle-brachial index (ABI) – ratio of blood pressure in the ankle compared to the arm (low ABI indicates PAD) – may require Doppler ultrasound for measurement
Skin examination of the legs and feet for:
Hair loss
Dry, shiny skin
Gangrene (blackened, dead tissue)
Ulcers (open sores)
Assessment
Peripheral artery disease (suspected) based on clinical presentation and physical exam findings
Severity of PAD:
Stage I: Asymptomatic (no claudication)
Stage II: Claudication present
Stage III: Rest pain
Stage IV: Tissue loss (ulceration or gangrene)
Consider differential diagnoses (neuropathy, musculoskeletal pain)
Plan
Diagnostic testing (may be ordered depending on presentation):
Ankle-brachial index (ABI) – confirm diagnosis and assess severity
Doppler ultrasound – evaluate blood flow in the legs
Arteriography (X-ray with contrast dye) – visualize blocked arteries (may be done before revascularization procedures)
Treatment:
Aims to improve blood flow, manage risk factors, and prevent limb loss
Lifestyle modifications:
Smoking cessation (crucial)
Healthy diet (low in saturated fat, cholesterol)
Exercise therapy (supervised walking program)
Weight management (if overweight or obese)
Medications:
Antiplatelet medications (aspirin, clopidogrel) to prevent blood clots
Statins to lower cholesterol levels
Medications to control diabetes and blood pressure
Revascularization procedures (considered in severe cases):
Angioplasty with stent placement to open narrowed arteries
Bypass surgery to create a new pathway for blood flow
Education
Explain the diagnosis and importance of risk factor management
Importance of smoking cessation and healthy lifestyle modifications
Skin care for the feet to prevent ulcers
Follow-up
Schedule for next appointment:
Monitor symptoms (claudication distance, rest pain)
Assess response to treatment
Repeat ABI to monitor progress
Consider referral to a vascular specialist for revascularization procedures if needed
Note: This is a template and may need to be modified based on the individual patient’s presentation, severity of PAD, and presence of complications.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of peripheral artery disease.