Admission History & Physical (Vascular Surgery)

Patient Name: [Full name]   MRN: [MRN]   Date of Birth: [DOB]   Admission Date/Time: [Admission date/time]   Note Date/Time: [Note date/time]   Facility/Unit: [Facility/unit]   Author: [Author name, role]   Source of History: [patient / family / EMS / outside records] (Note reliability and interpreter use if applicable)

Chief Complaint

[Patient-stated symptom or reason for admission] (Include brief direct quote when helpful. For transfers, include transfer diagnosis and reason.)

History of Present Illness

[One-sentence patient summary: age, key comorbidities, relevant vascular history, reason for admission]

[Chronologic symptom narrative including onset, duration, progression, triggers, relieving factors, and impact on activity/sleep] (Include only pertinent negatives that affect triage or procedural decisions.)

Ischemic limb features: [Rest pain presence/timing/severity] [Tissue loss] [Claudication distance] [Nocturnal pain] [Dependency relief] (Include only if relevant to presentation.)

Aneurysm features: [Pain location/character] [Syncope] [Hypotension episodes] (Include only if relevant.)

Infection features: [Fever/chills] [Wound drainage] [Bacteremia history] [Prior/ongoing antibiotics with start dates] (Include only if relevant.)

Prior vascular history: [Prior interventions with dates: bypass (conduit/target/side), endarterectomy, stents, EVAR/TEVAR, thrombectomy, amputations (level/side)] [Prior imaging with dates and key findings]

Current limb/organ threat and baseline function: [Tissue loss presence] [Infection concern] [Baseline ambulation and ADLs] [Assistive devices] [Patient goals regarding limb salvage vs palliation if discussed]

Medications relevant to immediate management: [Antiplatelets: agent(s), last dose time] [Anticoagulants: agent, indication, last dose time] [Statin] [Antibiotics: agent(s), start date] [Diabetes therapy: insulin/orals, last dose] (State "Unknown" when not available; do not infer.)

Past History

Past Medical History: [CAD/MI, heart failure, valvular disease, arrhythmia, stroke/TIA, CKD/ESRD, diabetes, COPD/OSA, prior VTE/thrombophilia, liver disease, malignancy, immunosuppression, bleeding history] (Include only items relevant to perioperative risk and vascular outcomes.)

Past Surgical/Procedural History: [Vascular procedures with laterality, conduit, target vessels, access sites, complications] [Non-vascular surgeries relevant to anesthesia/positioning/anticoagulation]

Medications: [Medication list with dose/frequency] (Highlight antithrombotics with last dose timing, statin intensity, antihypertensives, diabetes regimen, chronic opioids, immunosuppressants.)

Allergies: [Drug and reaction type] [Contrast reaction type/severity if any] [Latex] [Chlorhexidine] (If none, state "No known drug allergies.")

Family History: [Aneurysm, premature CAD, clotting disorders] (Include only if relevant.)

Social History: [Tobacco status with pack-years, current/former] [Alcohol] [Substances] [Housing stability] [Support system/caregiver availability] [Wound care capability] [Baseline mobility and assist devices]

Functional/Baseline Status: [Pre-admission ambulation] [ADL independence] [Falls history] [Baseline cognition] [Nutrition risk/unintentional weight loss]

Review of Systems

(Include only if patient can participate and ROS informs differential or risk. If unreliable historian or critical illness, write: "ROS limited/unobtainable due to [reason]" and omit detailed review.)

• Constitutional: [Fever/chills, weight loss]
• Cardiovascular/Respiratory: [Chest pain, dyspnea, orthopnea, PND]
• Neurologic: [Focal deficits, dizziness/syncope]
• GI: [GI bleed symptoms, abdominal pain] (Include if fistula concern.)
• Limb-specific: [Pain, numbness, weakness, coldness, color change]
• Skin/Wound: [Ulcerations, drainage, erythema, odor]

Physical Examination

Vitals: [Temp, HR, BP, RR, SpO2, pain score, oxygen requirement]

General: [Appearance/distress level]

Cardiovascular: [Rate/rhythm, murmurs, JVD, peripheral edema]

Respiratory: [Breath sounds, work of breathing, oxygen support]

Abdomen: [Soft/tender/distended, masses, pulsatile mass present/absent]

Extremities/Skin: [Edema, temperature, color changes, skin integrity, signs of venous disease]

Vascular Examination:

• Pulses: [R femoral, popliteal, DP, PT; L femoral, popliteal, DP, PT] (Grade 0-2+ or document Doppler signal as present/absent with waveform: monophasic/biphasic/triphasic. Example format: "R femoral 2+, popliteal 1+, DP Doppler monophasic, PT absent; L femoral 2+, popliteal 2+, DP 1+, PT Doppler monophasic.")
• Perfusion: [Capillary refill, temperature, color, dependent rubor, pallor on elevation]
• Bruits: [Carotid, femoral, abdominal, renal] (Include if assessed.)

Wound/Limb Assessment: (Required for CLTI/tissue loss; if no wound, state "No wounds identified.")

• Location/Laterality: [Anatomic location and side]
• Size: [Length x width x depth]
• Base: [Granulation/slough/eschar, necrosis/gangrene extent]
• Drainage: [Character, amount, odor]
• Surrounding tissue: [Erythema, warmth, induration, lymphangitis]
• Fluctuance/Crepitus: [present / absent]
• Probe-to-bone: [positive / negative / not performed]
• Sensation/Motor: [Intact/diminished/absent, motor strength of affected extremity]

Neurologic: [Mental status, motor, sensation, focal deficits]

Diagnostics / Data Reviewed

Laboratory Data: [CBC, BMP, lactate, coagulation studies, inflammatory markers, blood cultures status] (List dates and notable abnormalities.)

Imaging: [Modality, date/time, key findings relevant to plan] (For outside images, note if requested/received and source of read.)

Noninvasive Vascular Studies: [ABI/TBI with waveforms, toe pressures, TcPO2/skin perfusion pressure, duplex findings with stenosis/occlusion locations and graft patency]

Cardiac Testing: [ECG findings, echocardiogram EF/valves/date, stress test/device interrogation]

Pending Studies: [Tests pending with expected timeframe]

Perioperative Risk Assessment

(Include when surgery or endovascular intervention is anticipated.)

Planned/anticipated procedure: [Procedure, open/endovascular/hybrid, urgency level, rationale]

Cardiovascular risk: [Known CAD/HF, functional capacity (METs), beta-blocker plan, antiplatelet/anticoagulation peri-procedural strategy]

Pulmonary risk: [COPD/OSA, smoking status, ventilation considerations]

Renal/contrast risk: [CKD/ESRD, dialysis schedule, nephroprotection plan]

Bleeding/transfusion risk: [Anemia/coagulopathy, type & screen/crossmatch, transfusion thresholds]

Infection risk: [Current antibiotics, source control strategy]

Frailty/goals: [Frailty assessment, anticipated rehab needs, code status, goals consistent with proposed intervention]

Assessment

[Concise summary tying presentation to suspected diagnosis and severity] (Include differential only when diagnostic uncertainty affects testing or therapy.)

• [Problem 1 – immediate threat]: [Assessment]
• [Problem 2 – limb/organ jeopardy]: [Assessment]
• [Problem 3 – comorbidities affecting intervention]: [Assessment]
• [Additional problems as applicable]

Plan

(Problem-oriented format. For high-acuity cases, list immediate priorities first with time-critical actions.)

• [Problem 1]: [Diagnostics ordered/pending] [Therapeutics: antibiotics/anticoagulation/analgesia with agents and doses] [Procedural planning: OR timing, access strategy, anesthesia coordination] [Monitoring: vitals frequency, neurovascular checks, lactate trend]
• [Problem 2 – CLTI/PAD if applicable]: [Revascularization evaluation: imaging plan, WIfI staging] [Wound care: dressings, offloading, debridement plan] [Antithrombotic/statin optimization] [Antibiotics and culture plan if infection suspected]
• [Aneurysm management if applicable]: [Hemodynamic monitoring level and targets] [Imaging plan with escalation thresholds] [Operative planning: approach, device needs, blood availability] [NPO status, consent status]
• [Graft infection if applicable]: [Diagnostic workup: CT/PET-CT, cultures, inflammatory markers] [Source control pathway] [Antibiotic plan with ID consultation]
• Antithrombotic management: [Continue/hold agents, bridging plan, last dose times]
• VTE prophylaxis: [Pharmacologic / mechanical / contraindicated with reason]
• Pain control: [Multimodal regimen]
• Glycemic management: [Insulin strategy, glucose targets]
• Renal protection/dialysis: [Fluids, contrast precautions, dialysis timing]
• Nutrition/Activity: [Diet, weight-bearing restrictions, PT/OT]
• Wound care orders: [Dressing type/frequency, offloading]
• Consults: [Anesthesia, Cardiology, ID, Podiatry, Nephrology, SW/Case management as applicable]
• Disposition planning: [Anticipated needs/barriers, home health/SNF/rehab, equipment]

Communication / Shared Decision-Making

(Include when procedures are likely or limb salvage vs amputation tradeoffs are discussed.)

[Participants in discussion] [Patient goals/priorities: function, limb salvage, survival] [Code status and alignment with proposed intervention] [Informed consent status: obtained / pending]

Contingency Planning

(Include for high-acuity admissions.)

• Worsening limb ischemia: [New rest pain, motor/sensory loss, loss of Doppler signals → escalate to emergent imaging/intervention]
• Aneurysm decompensation: [Hemodynamic instability, expanding pain, falling Hgb → activate massive transfusion/OR alert]
• Sepsis progression: [Fever, hypotension, rising lactate, altered mental status → broaden antibiotics, repeat cultures, escalate level of care]
• Bleeding/fistula concern: [Sentinel bleed, GI bleeding, expanding hematoma → immediate surgical evaluation]