Arterial Ulcer/Critical Limb Ischemia Evaluation Note

Date/Time: [Date and time of encounter]

Setting: [wound clinic / inpatient consult / ED / home visit]

Author: [Clinician name and credentials]

Referral Source: [Self-referred / Primary care / ED / Inpatient team / Podiatry / Other]

Limb Laterality Focus: [Right / Left / Bilateral]

Chief Complaint

[Single-sentence description of wound concern and reason for evaluation]

Clinical Summary

[One to two sentences summarizing patient age, key risk factors (diabetes, smoking, CKD/dialysis, known PAD), wound location and duration, primary ischemia signal (e.g., absent pulses, monophasic Doppler, low toe pressure, dependent rubor), and immediate disposition (e.g., urgent vascular referral placed, ED transfer, testing ordered)]

History of Present Illness

[Wound onset and precipitating event; wound course and prior treatments; history of prior ulcers or amputations with laterality and dates if known] (Organize into 1–2 cohesive paragraphs. If information is unknown, state "unknown" rather than "denies.")

[Ischemic symptoms: rest pain features (location, nocturnal timing, relief with dependency), claudication features (muscle group, walking distance), tissue loss symptoms (discoloration, eschar, gangrene)]

[Acute limb ischemia screening: abrupt onset severe pain, cold limb, sudden sensory loss, motor weakness; if present, document time last known normal and immediate escalation plan]

[Infection symptoms: increasing redness, swelling, purulence, fever/chills]

[Prior vascular testing with dates (ABI/TBI/toe pressures); prior imaging (duplex/CTA/MRA/angiography); prior revascularization or amputations with dates and laterality] (Note "per report" if external and whether original report was reviewed.)

[Cardiovascular risk factors: diabetes control, smoking status, CKD stage/dialysis, CAD/CVA history; current antiplatelet/anticoagulant/statin therapy and adherence]

Background

Past Medical History:

• [Peripheral arterial disease (PAD)]
• [Diabetes mellitus (type and control)]
• [Chronic kidney disease (stage) / dialysis status]
• [Coronary artery disease]
• [Heart failure]
• [Atrial fibrillation]
• [Stroke/TIA]
• [Peripheral neuropathy]
• [Foot deformities (e.g., Charcot, bunion, hammertoes)]

Past Surgical History: [Revascularizations (type, approach, target vessels, dates); amputations (level, laterality, dates); other relevant surgeries]

Social History: [Tobacco use (pack-years, current status); mobility baseline (assistive devices, walking capacity); caregiver support for wound care]

Allergies: [Medications, contrast agents, antibiotics with reaction types]

Physical Examination

Vitals

[Temperature] [Heart rate] [Blood pressure] [Respiratory rate] [SpO2] [Pain score]

General

[Overall appearance: toxic / nontoxic / ill-appearing / comfortable]

Vascular and Perfusion Exam

• Pulse examination (0=absent, 1+=diminished, 2+=normal):
  • Right: Femoral [0 / 1+ / 2+], Popliteal [0 / 1+ / 2+], Posterior tibial [0 / 1+ / 2+], Dorsalis pedis [0 / 1+ / 2+]
  • Left: Femoral [0 / 1+ / 2+], Popliteal [0 / 1+ / 2+], Posterior tibial [0 / 1+ / 2+], Dorsalis pedis [0 / 1+ / 2+]
• Doppler signals: (Document for diminished or absent pulses.)
  • Right: DP [present / absent], waveform [triphasic / biphasic / monophasic / unable to obtain]; PT [present / absent], waveform [triphasic / biphasic / monophasic / unable to obtain]
  • Left: DP [present / absent], waveform [triphasic / biphasic / monophasic / unable to obtain]; PT [present / absent], waveform [triphasic / biphasic / monophasic / unable to obtain]
• Perfusion signs:
  • Skin temperature: [cooler / warm / symmetric to contralateral]
  • Color: [pallor / cyanosis / mottling / rubor / normal]
  • Elevation pallor / dependent rubor: [present / absent / not assessed]
  • Capillary refill: [seconds, or delayed / normal]
  • Trophic changes: [hair loss / shiny atrophic skin / nail dystrophy / none]
  • Edema: [none / mild / moderate / severe]
• Neuromotor status: Sensation to light touch [intact / diminished / absent]; motor strength toe/ankle [normal / weak]; new deficits [yes (describe) / no]

Wound Assessment

• Wound inventory: [Number of wounds], [Laterality], [Anatomic location(s)]
• Measurements: [Length × width × depth in cm]; undermining/tunneling [clock-face direction and depth] (If unable to measure, document reason and provide estimate.)
• Exposed structures: [none / tendon / capsule / bone]
• Wound bed: [% granulation], [% slough], [% eschar/necrosis]
• Drainage: [none / scant / moderate / heavy]; character [serous / serosanguinous / purulent]; odor [absent / present]
• Margins: [punched-out / irregular / macerated / callused]
• Periwound skin: [intact / maceration / erythema / induration / warmth]
• Infection signs: Erythema [cm from wound edge], warmth [present / absent], induration [present / absent], tenderness [present / absent], purulence [present / absent], crepitus [present / absent], wet gangrene [present / absent]
• Probe-to-bone: [performed: positive / negative / not performed] (Include for diabetic foot ulcers.)

Diagnostic Data

• Noninvasive vascular testing: [Test type: ABI / TBI / toe pressures / segmental pressures-PVR / TcPO2 / SPP], date [date], facility [facility], results [numeric values and interpretation: normal / borderline / abnormal / noncompressible per limb] (If ABI noncompressible, explicitly note limitation.)
• External results: [per report; original document reviewed: yes / no]
• Arterial imaging: [Duplex / CTA / MRA / angiography], date [date], key findings [findings by limb/segment] (Include only if available.)
• Laboratory data: [WBC, hemoglobin, creatinine/eGFR, CRP/ESR, A1c] (Include selectively based on clinical relevance.)

Assessment

Primary impression: [Arterial insufficiency ulcer suspected / Meets criteria for CLTI / Concern for CLTI—objective testing pending] (State explicitly with brief supporting rationale.)

[For mixed etiology wounds, document both components and note that compression and debridement decisions depend on perfusion assessment.]

WIfI staging: W [0–3], I [0–3], fI [0–3] (If incomplete, state which component is missing and why.)

Infection severity: [uninfected / mild / moderate / severe]

[Differential diagnosis] (Include only if it changes management.)

Plan

Vascular Evaluation and Referral

• Disposition: [Emergent ED transfer for ALI concern / Urgent vascular referral for CLTI with target timeframe / Routine vascular referral]
• Testing ordered: [ABI / TBI / toe pressures / segmental pressures-PVR / TcPO2 / SPP] (If ABI noncompressible, specify alternate testing.)
• Closed-loop communication: [Who contacted, method, date/time, response/outcome]
• Imaging plan: [Arterial duplex / CTA / MRA / diagnostic angiography; renal function and contrast allergy considerations noted] (Include if indicated.)

Wound Management

• Wound care: [Protective care pending revascularization assessment: cleansing, dressing type, moisture balance]
• Offloading: [Device type (post-op shoe, CAM boot, total contact cast); weight-bearing limits; footwear guidance]
• Precautions: [Interventions avoided pending perfusion clarification (compression, aggressive debridement)]
• Follow-up interval: [Timeframe for wound reassessment]

Infection Management

(Include if infection present; omit if uninfected.)

• Wound culture: [Type and timing]
• Antibiotic therapy: [Agent(s), dose, route, duration, rationale]
• Escalation triggers: [Spreading cellulitis, systemic signs, wet gangrene; surgical/podiatry consult timing]

Pain Management

• [Analgesic regimen; opioid safety counseling if prescribed]

Cardiovascular Risk Reduction

• Smoking cessation: [Counseling provided, pharmacotherapy offered, referral status]
• Statin therapy: [Current agent/intensity, optimization plan, responsible prescriber]
• Antiplatelet/antithrombotic: [Current status, plan, responsible prescriber]
• Glycemic/BP optimization: [Plan and coordinating clinician] (Include if applicable.)

Patient Education

• [Explanation of ischemia and limb threat; risks discussed (nonhealing, infection, amputation, cardiovascular events)]
• [Return precautions: worsening pain, coldness, numbness, spreading redness, fever, blackening tissue]

Follow-up

• Wound clinic: [Date/time]
• Vascular appointment: [Requested / Scheduled / Confirmed (date/time)]
• Records sent: [Tests, images, photos, summary note sent to vascular team]
• Referral barriers: [Insurance, transportation barriers and mitigation plan] (Include if applicable.)

Procedures

(Include only if procedures were performed; omit section entirely otherwise.)

• Handheld Doppler assessment: [Sites assessed and signals/waveforms documented]
• Debridement: [Type (selective/sharp/mechanical), tissue removed, area treated, anesthesia, hemostasis, tolerance]
• Dressing applied: [Primary and secondary dressing, securement]
• Offloading device provided: [Device type and instructions given]