Preoperative Evaluation Note (Vascular Surgery)

Date/Time: [Date and time of encounter]
Patient: [Full name]
DOB: [MM/DD/YYYY]
Encounter Setting: [clinic / inpatient / pre-admission testing] - [location]
Planned Procedure: [Primary procedure with laterality] [± possible adjuncts/contingencies]
Planned Date of Surgery: [MM/DD/YYYY or TBD]
Surgeon of Record: [Name, credentials]
Source of History: [patient / family or caregiver / interpreter / outside records]

Preoperative Summary

[3–6 sentence narrative summary including: indication and why now, explicit current symptom status, key imaging with date and decisive findings, planned approach and target vessel/territory, and top 2–3 optimization priorities]

Chief Concern

[Single-line reason for preoperative evaluation, e.g., "Pre-op evaluation for elective carotid endarterectomy"]

History of Present Illness

[Narrative of indication, symptom trajectory with dates, prior interventions and responses, functional impact, and patient goals/preferences] (Explicitly state current symptom status rather than implying from diagnosis.)

Disease-specific symptom status: (Include applicable section; use explicit placeholders if unknown, e.g., "Date of last TIA: unknown")

• Carotid disease: [symptomatic / asymptomatic]; if symptomatic: [event type: TIA / stroke / amaurosis fugax], [date of last event], [residual deficits], [current neurologic baseline]
• PAD/CLTI: [asymptomatic PAD / chronic symptomatic PAD / CLTI]; if claudication: [walking distance and functional impact]; if CLTI: [rest pain duration], [ulcer/gangrene >2 weeks], [infection signs], [wound care to date]
• Aneurysmal disease: [symptomatic / asymptomatic]; if symptomatic: [pain characteristics]; [growth history with dates if available]

Prior vascular interventions: [Procedure, date, laterality/location, outcomes, complications]

Disease Staging and Anatomy

(Include only when objective staging data exist. Omit entire section if not applicable.)

Carotid Disease (Include only if carotid indication)

• [Laterality] carotid stenosis [severity %] by [duplex / CTA / MRA / angiography], [date]
• Contralateral carotid/vertebral disease: [summary]
• Prior carotid interventions: [CEA / CAS / TCAR, dates, outcomes]
• Planned modality: [CEA / CAS / TCAR]; rationale: [anatomic/clinical considerations]

Lower Extremity PAD/CLTI (Include only if LE indication)

• Hemodynamics: ABI [R/L values, date] (note if noncompressible); toe pressures/TBI [values, date]
• Wound(s): [location], [size L×W×D], [necrosis], [infection], [exposed structures]
• WIfI staging: W[0–3] / I[0–3] / fI[0–3], [date]
• Anatomic disease pattern: [aortoiliac / femoropopliteal / tibial] with key lesions
• Planned intervention: [endovascular / open bypass / hybrid], target: [vessel/segment], conduit: [vein mapping status or conduit choice]

Aortic Aneurysm (Include only if aneurysm indication)

• Maximum diameter: [cm] by [CTA / ultrasound / MRA], [date]; morphology: [fusiform / saccular]; level: [infrarenal / juxtarenal / suprarenal]
• Planning anatomy: [proximal neck], [angulation], [iliac access], [branch involvement]
• Planned approach: [EVAR / open]; rationale: [anatomic/clinical considerations]

Comorbidities and Surgical History

• CAD / prior MI / PCI / CABG: [details with years]; angina status: [stable / unstable / none]
• Heart failure: [HFrEF / HFpEF], NYHA class [I–IV], EF [%] ([date])
• Valvular disease: [type and severity]; endocarditis history: [yes / no]
• Arrhythmias: [AFib / other]; devices: [pacemaker / ICD / none]
• Prior stroke/TIA: [dates], [residual deficits]
• Diabetes: [Type 1 / Type 2], A1c [%] ([date]), [complications]
• CKD: Stage [1–5], baseline Cr [value] / eGFR [value] ([date])
• COPD / asthma; OSA: [details, CPAP use]
• Bleeding history / coagulopathy; HIT history: [details]
• Prior vascular surgeries: [procedure, year, laterality]
• Other relevant conditions: [details]

Medications and Perioperative Plan

Current Medications

• Antiplatelet(s): [agent, dose, indication]
• Anticoagulant: [agent, dose, indication]
• Statin: [agent, dose]
• Antihypertensives: [list with doses]; beta-blocker: [yes / no]
• Diabetes medications: [insulin regimen, oral agents including metformin, SGLT2i, GLP-1]
• Other relevant medications: [list]

Allergies: [Allergen] — [reaction type] (Note especially: iodinated contrast, heparin/HIT, prophylactic antibiotics, latex)

Perioperative Medication Plan

• Antiplatelet(s): [continue / hold]; timing: [specific timing / to be coordinated]
• Anticoagulant: [continue / hold]; indication: [indication]; procedure bleeding risk: [low / moderate / high]; bridging: [plan to be finalized with cardiology/anticoagulation clinic] (Do not generate bridging plan without documented thrombotic risk context.)
• Statin: [continue / initiate / up-titrate]
• Beta-blocker: [continue if chronic / not indicated for new initiation]
• Diabetes agents: [insulin adjustment], metformin [continue / hold per renal function], SGLT2i [hold 3–4 days pre-op], GLP-1 [hold day of surgery if indicated]
• Other: [ACE/ARB plan], [diuretics], [supplements/herbals to hold]

Social History

• Tobacco: [current / former / never], [pack-years], last use: [date]. Cessation counseling: [performed / not performed]; readiness: [pre-contemplative / contemplative / preparation / action]; resources provided: [pharmacotherapy / quitline / referral]
• Alcohol: [none / social / moderate / heavy] (Include if relevant to withdrawal risk.)
• Substance use: [type, frequency] (If relevant to anesthesia or wound/infection risk.)
• Support system: [caregiver availability], [transportation plan], [ability to adhere to postoperative surveillance]

Physical Examination

(Do not auto-populate normal findings. If exam not performed, state explicitly.)

• Vitals: BP [value], HR [value], SpO2 [value]
• General: [Appearance, distress level, ambulatory status]
• Cardiovascular: [Rate/rhythm], [murmurs], [JVD], [edema]
• Pulmonary: [Effort], [breath sounds], [adventitious sounds]
• Abdomen: [Tenderness], [pulsatile mass if applicable], [surgical scars]
• Vascular: Pulses — carotid R[0–3+]/L[0–3+], femoral R/L, popliteal R/L, DP R/L, PT R/L; bruits [carotid / femoral: present / absent]; limb temperature [warm / cool]; capillary refill [normal / delayed]; edema [present / absent]; wounds [description if present]
• Neurologic: (For carotid patients) [Cranial nerves], [speech], [motor function], [focal deficits]

(If telehealth or limited exam: "Exam not performed due to [reason]; assessment based on history and available data.")

Diagnostics Reviewed

Imaging (Include only if available)

• [Modality], [date], [facility]: [Key decision-driving findings]. Images: [personally reviewed / report only; images not available]

Labs (Include only if available)

• CBC: Hgb [value], Plt [value], [date]
• Renal: Cr [value], eGFR [value], K [value], [date]
• A1c: [value], [date] (if diabetic)
• Coagulation: INR [value], PTT [value], [date] (if applicable)

Cardiac/Pulmonary Testing (Include only if available)

• ECG: [date], [key findings]
• Echocardiogram: [date], EF [%], [valve findings]
• Stress test: [date], [modality], [result], [management implications]
• PFTs / sleep study: [results if relevant]

Perioperative Risk Assessment and Optimization

(Include only applicable domains; omit subsections that do not apply.)

• Cardiovascular: Functional capacity: [METs or activity level]. Risk stratification: [tool used, result]. Additional cardiac testing: [indicated / not indicated] — [rationale]. BP optimization: [plan]
• Antithrombotic management: Agent(s)/indication(s): [list]. Procedure bleeding risk: [low / moderate / high]. Plan: [continue / hold, timing]. Bridging coordination: [service and timeline]
• Vascular medical therapy: Statin: [on / initiate / up-titrate]. Antiplatelet plan: [aligned with procedure type]
• Diabetes: Perioperative plan: [insulin adjustment, SGLT2i hold 3–4 days, metformin per renal function]. Coordination: [endocrinology / PCP if needed]
• Renal/contrast risk: Baseline Cr/eGFR: [values]. CIN risk: [low / moderate / high]. Strategy: [hydration, contrast minimization, avoid nephrotoxins]
• Pulmonary and smoking: COPD/OSA status: [details]. Cessation timeline goal: [target]. Plan: [pharmacotherapy, referrals]
• Infection/wound readiness: Active infection: [yes / no]. MRSA risk: [low / high]. Antibiotic prophylaxis: [considerations]. Wound optimization: [local care, debridement timing]
• Nutrition/anemia/frailty: (If risk signals present) [Albumin, Hgb, weight loss, gait speed]. Optimization: [nutrition consult, iron/ESA, prehab]. Discharge planning: [home support / SNF]

Assessment

1. [Primary diagnosis with laterality, severity/stage, symptom status]. Evidence: [key objective findings with date]. Rationale for intervention: [brief justification]
2. [Secondary diagnosis]. Evidence: [supporting data]
3. [Additional diagnoses as relevant]

Plan

Operative Plan

• Procedure: [planned procedure], [open / endovascular / hybrid], [laterality]
• Preoperative tasks: [labs], [imaging], [vein mapping], [consults], [medication holds], [smoking cessation steps]
• Day-of-surgery medications: [medications to take/hold] (Anesthesia fasting instructions per facility protocol.)
• Postoperative expectations: [antithrombotic resumption], [surveillance schedule], [wound care], [follow-up timing]
• Contingencies: [triggers for urgent evaluation, conversion thresholds, staged procedures]

Additional Problem-Specific Plans

• [Problem]: [Management steps, coordination]

Informed Consent

(Include only if consent was obtained or meaningfully discussed at this encounter.)

• Nature and purpose of procedure: [discussed]
• Material risks discussed: [stroke / MI / bleeding / infection / renal injury / nerve injury / limb loss / contrast reaction / conversion / death, as applicable]
• Expected benefits: [summary]
• Alternatives discussed: [including nonoperative management]
• Risks of no treatment: [summary]
• Patient questions: [addressed / none]. Decision: [consented / deferred / requests second opinion]. If deferred: [reason and next steps]

H&P Status

This note serves as the preoperative H&P: [Yes / No]
(If No: Prior H&P by [author] on [date]. Interval changes: [summary]. Updated exam: [performed / not performed — reason].)