CLTI Limb-Salvage Evaluation Note (WIfI/Objective Ischemia)

Date: [Date]
Patient Name: [Patient full name]
DOB: [Date of birth]
Referring Provider: [Referring clinician and specialty]
Limb(s) Evaluated: [Right / Left / Bilateral]

Limb-Salvage Snapshot

Reason for Evaluation: [Consult question or evaluation purpose in one sentence]

Limb Threat Summary: [Laterality]; [Tissue loss type: ulcer / dry gangrene / wet gangrene / rest pain only]; [Duration of tissue loss >2 weeks: yes / no / unknown]; [Systemic illness flags: fever / sepsis concern / hemodynamic instability / none]

WIfI Severity:
W grade: [0 / 1 / 2 / 3] — [Brief wound descriptor]
I grade: [0 / 1 / 2 / 3] — [Supporting perfusion metric with value and units] (Toe pressure/TBI preferred; note if ABI unreliable.)
fI grade: [0 / 1 / 2 / 3] — [Infection criteria summary]
Stage: [1 / 2 / 3 / 4 / Stage pending — specify missing component(s)] (Calculate only if all components supported; otherwise state "partial WIfI" with available components.)

Objective Ischemia Highlights:

• [ABI Right/Left with interpretive comment] (Note if noncompressible/falsely elevated.)
• [Toe pressure and TBI Right/Left with units]
• [Pedal Doppler waveforms DP/PT Right/Left: triphasic / biphasic / monophasic / absent]
• [TcPO₂ and/or SPP with site(s) and units] (Include if obtained.)
• Limitations: [Calcified arteries / prior amputation / severe edema / dressings / patient intolerance / none]

Anatomic Summary: [Arterial disease distribution if known: inflow disease / femoropopliteal disease / tibial runoff / pedal arch status; or planned imaging modality and timing if not yet obtained]

Limb-Salvage Strategy Headline: [Urgency: urgent / expedited / outpatient] — [Sequence: infection source control first / revascularization first / concurrent] — [Revascularization: endovascular / bypass / hybrid / not recommended] — [Major amputation discussion: indicated / not indicated / to be revisited]

History of Present Illness

[Chronological narrative focused on the limb problem] (Include onset and progression of rest pain, ulcer, or gangrene with duration and precipitating event; prior wound care and offloading with adherence barriers; prior vascular interventions and amputations with levels and dates; infection course including drainage, odor, erythema progression, prior antibiotics with agents and dates, culture results; pain characteristics and night/dependency pattern; functional baseline and patient goals; and the trigger for current evaluation.)

CLTI Risk Profile

• Diabetes: [Duration, recent HbA1c, neuropathy status]
• Renal: [CKD stage / dialysis status / not applicable]
• Cardiac: [CAD / CHF / none]
• Smoking: [Current / former / never; pack-years if available]
• Neurologic: [Prior stroke or TIA / none]
• Thrombosis/bleeding: [Relevant history for antithrombotic planning]
• Contrast considerations: [Allergy / prior contrast nephropathy / none]
• MRI contraindications: [Present / none]

Medications

• Antithrombotic: [Antiplatelet/anticoagulant therapy with doses; note adherence or contraindications]
• Lipid-lowering: [Statin and other agents]
• Antihypertensives: [Current regimen]
• Diabetes medications: [Oral agents and/or insulin regimen]
• Antibiotics: [Current or recent antibiotics with start/stop dates]
• Analgesics: [Current regimen and response]

Allergies

• [Antibiotic allergies and reaction type]
• [Contrast agent allergies and reaction type]
• [Other relevant allergies]

Physical Examination

Vitals: [Temperature, HR, BP, RR, SpO₂] (Temperature and hemodynamics required when infection is a consideration.)

Vascular Exam: (Document by limb; duplicate if bilateral.)

• Right: Pulses [Femoral / Popliteal / DP / PT: palpable / Doppler-only / absent]; Capillary refill [seconds]; [Dependent rubor / elevation pallor / neither]; Skin temperature [warm / cool / cold]; Edema [none / trace / 1+ / 2+ / 3+]; [Surgical scars or access sites]
• Left: Pulses [Femoral / Popliteal / DP / PT: palpable / Doppler-only / absent]; Capillary refill [seconds]; [Dependent rubor / elevation pallor / neither]; Skin temperature [warm / cool / cold]; Edema [none / trace / 1+ / 2+ / 3+]; [Surgical scars or access sites]

Neurologic: Protective sensation [intact / diminished / absent] by [monofilament / tuning fork / clinical exam]; Motor deficits [present — describe / none]

Musculoskeletal: [Deformities: Charcot changes / prominent metatarsal heads / claw toes / hammertoes / none]; Achilles tightness [present / absent]; [Gait and offloading tolerance]

Wound Inventory

(Include only if ulcer or gangrene is present. Create a separate block for each wound.)

Wound #1 — [Laterality] [Location using standardized foot map terms]

• Etiology: [Neuropathic / Neuro-ischemic / Ischemic / Surgical / Traumatic]
• Dimensions: [L × W × D cm] (Date: [date measured])
• Wound bed: [Granulation __ % / Slough __ % / Eschar __ %]
• Margins: [Undermining or tunneling: depth and clock-face direction / none]
• Exudate: [Amount: none / scant / moderate / copious]; [Character]; [Odor: present / absent]
• Periwound skin: [Maceration / callus / erythema __ cm from margin / fluctuance / crepitus / unremarkable]
• Exposed structures: [Tendon / bone / joint / none]
• Photo documentation: [Obtained / declined / unavailable]

(Repeat wound block for additional wounds as applicable.)

Infection Assessment

(Include only if infection concern exists. Keep separate from wound bed description.)

• Infection Severity Classification: [Uninfected / Mild / Moderate / Severe] (Document osteomyelitis separately if suspected or confirmed.)
• Local signs: [Warmth / swelling-induration / tenderness / erythema __ cm from margin / purulence / lymphangitis / necrosis / bullae / rapid progression]
• Systemic signs: [Temperature / HR / RR / WBC] (Document SIRS criteria if present.)
• Osteomyelitis evaluation: Probe-to-bone [positive / negative / not performed]; Sinus tract [present / absent]; Bony exposure [present / absent]
• Microbiology: [Specimen type: superficial swab / deep tissue / bone biopsy] obtained [date] (If no culture, state reason and plan.)
• Labs: WBC [value], ESR [value], CRP [value], Procalcitonin [value if obtained], Cr [value] (Date: [date])
• Imaging: Plain X-ray [findings / pending / not obtained]; MRI [findings / pending / not indicated]

Objective Ischemia Testing

Test Provenance: [Date, facility, and source: performed by author / reviewed from outside records / pending]

• ABI: Right [value], Left [value] (Cuff level: [high-thigh / low-thigh / calf / ankle]; [Normal / falsely elevated due to calcification / noncompressible])
• Ankle systolic pressure: Right [value mmHg], Left [value mmHg]
• Toe pressure and TBI: Right [pressure mmHg, TBI value] (Toe: [great / second]; Method: PPG), Left [pressure mmHg, TBI value]
• Pedal Doppler waveforms: Right DP [triphasic / biphasic / monophasic / absent], PT [triphasic / biphasic / monophasic / absent]; Left DP [waveform], PT [waveform]
• TcPO₂: [Site(s) and value(s) mmHg] (Include if obtained.)
• SPP: [Site(s) and value(s) mmHg] (Include if obtained.)
• PVR/Segmental pressures: [Key levels and pressure gradient or drop-off] (Include if obtained.)

Test Conditions and Limitations: [Patient position / room temperature / edema / pain / calcification / prior amputations / bandages / other factors] (If results discordant, specify which metric is prioritized for clinical decision-making and why.)

Objective Ischemia Conclusion: [Summary: objective ischemia consistent with limb threat present / absent / indeterminate] — [Supporting data]. (If insufficient data, state exactly what is missing and plan to obtain it.)

Assessment

1. CLTI with [tissue loss / rest pain]: [Laterality], WIfI Stage [1 / 2 / 3 / 4 / partial]. Status: [worsening / stable / improving]. [Key supporting evidence and uncertainties requiring resolution.]
2. Diabetic foot infection and/or osteomyelitis: [Severity classification], [Laterality]. Status: [worsening / stable / improving]. [Supporting evidence.] (Omit if no infection.)
3. Diabetes and neuropathy: [Status and issues impacting wound healing or offloading.]
4. Cardiovascular risk optimization: [Lipid / BP / smoking / antithrombotic considerations.]
5. Additional problems: [Pain management / functional impairment / social barriers / other.] (Omit if none.)

Plan

• Revascularization: Candidacy: [Recommended / Not recommended / Pending workup]. Approach: [Endovascular / Bypass / Hybrid] with rationale based on [anatomy / limb severity / patient risk]. Prerequisites: [Imaging modality and timing; vein mapping if bypass]. Perfusion goal: [Target metric for wound healing]. Alternatives discussed: [Palliative wound care / primary amputation / comfort-focused care]. Shared decision-making: [Patient goals and preferences].
• Infection Management: [If uninfected: Antibiotics not indicated.] [If infected: Empiric regimen and rationale; culture-directed adjustment plan; duration and route; admission criteria if applicable; surgical drainage/debridement plan.] [Osteomyelitis pathway: medical vs surgical management.]
• Wound Care: Debridement: [Timing, setting]. Dressing: [Strategy and goal]. Monitoring: [Measurement intervals, photo frequency, area reduction targets].
• Offloading: Device: [Type]. Contraindications: [If any]. Adherence barriers: [If any]. Follow-up: [Reassessment plan].
• Medical Optimization: Antithrombotic: [Plan]. Lipid-lowering: [Plan]. Blood pressure: [Plan]. Smoking cessation: [Counseling, pharmacotherapy, or referral]. Diabetes: [Optimization plan and glycemic targets].
• Pain Management: Rest pain: [Regimen]. Dependency counseling: [Provided / not applicable]. Red flags: [Worsening ischemia indicators reviewed with patient].
• Follow-up and Safety Net: Follow-up: [Interval] to reassess [wound measurements / infection signs / perfusion metrics / post-procedure surveillance]. Return precautions: [Fever, rapidly spreading erythema, worsening pain, new drainage or odor, tissue blackening, systemic symptoms].

Procedures Performed

(Include only if procedures performed during encounter.)

• [Procedure name], [Laterality]: Consent [obtained / not required]. Technique: [Description]. Findings: [Description]. Complications: [None / describe]. Specimens: [Sent for culture / pathology / none].

Studies Reviewed

• [Noninvasive vascular studies: date, facility, key findings]
• [CTA / MRA / Angiography: date, key findings]
• [X-rays or other imaging: date, key findings]
• [Labs: date, pertinent results]
• [Culture results: date, source, organisms]
• [Outside records: source, summary of relevant findings]

Documentation reminders: Document laterality for every limb-specific finding. Do not infer objective ischemia grade without numeric perfusion data. Do not label wound as infected unless diagnostic criteria documented; if uncertain, mark as "equivocal" with clarification plan. Calculate WIfI stage only when all component grades are supported; otherwise report as partial WIfI with missing elements specified. For missing key inputs, document as "not obtained" with reason or "pending" with expected date. Include method, units, and limitations for all perfusion metrics.