Vascular Surgery Consultation Note (Inpatient)

Date/Time of Evaluation: [Date and time of consult evaluation]

Patient Location: [ED / ICU / floor / other inpatient unit]

Consulting Clinician(s): [Name(s), role(s), service]

Requesting Service/Clinician: [Service and clinician name]

Evaluation Method: [bedside / telephone/curbside / chart review only] (If not bedside, state: "No in-person exam performed; assessment based on available documentation and data.")

Reason for Consult

[Consult question in one sentence, including who requested the consult, what change prompted the request, and what immediate decisions are sought]

Triage: [emergent / urgent / non-urgent] — [Rationale describing threat level and key findings driving urgency] (Include this bolded triage statement only for time-sensitive problems such as threatened limb, active bleeding, or threatened access; omit for routine consults.)

History of Present Illness

[Time-anchored narrative of current problem including: symptom onset date/time and trajectory; precipitating event if any; prior vascular interventions with laterality and approximate dates; current antithrombotic status with last dose timing; symptom characterization; relevant comorbidities affecting candidacy] (When information is unavailable, state explicitly, e.g., "Symptom onset: unknown—patient unable to provide history." Do not infer times, doses, or procedure details without a documented source.)

(For suspected acute limb ischemia:) [6 Ps assessment: pain, pallor, pulselessness, poikilothermia, paresthesias, paralysis]; [Baseline limb function/pulses]; [Suspected etiology: embolic / thrombotic / acute-on-chronic]

(For postoperative bleeding/hematoma:) [Index procedure]; [Postoperative day]; [Drain output trends]; [Wound changes and hemorrhage characteristics]

(For iatrogenic access-site complications:) [Access site]; [Sheath size]; [Closure device used]; [Symptoms: expanding mass, neuropathy, distal ischemia, bleeding]

(For dialysis access complications:) [Access type and location]; [Last successful dialysis]; [Cannulation difficulties]; [Prolonged bleeding]; [Steal symptoms]; [Access pain, swelling, or infection signs]

Pertinent History and Medications

• Vascular history: [PAD, prior revascularizations with laterality, aneurysm history, prior amputations, prior access creations/revisions]
• Cardiac/embolic risk factors: [Atrial fibrillation, valve disease, recent MI, LV thrombus]
• Bleeding/clotting history: [Known thrombophilia, HIT, recent VTE, prior bleeding events]
• Renal disease/dialysis: [CKD stage, ESRD status, dialysis schedule]
• Diabetes/wound history: [Glycemic control, ulcers/wounds, prior infections]
• Anticoagulants: [Agent, dose, last dose time; INR if on warfarin] (If unknown, state pending verification.)
• Antiplatelets: [Agent(s), dose(s), last dose time]
• Vasopressors: [Agent(s) and dose(s)] (Include only if applicable.)
• Contrast allergy: [yes / no]; [Premedication status if imaging planned]

Review of Systems

[Targeted ROS relevant to the consult question] (Include only pertinent positives and key negatives. For ALI: chest pain, palpitations, dyspnea, neurologic symptoms. For bleeding: dizziness, syncope, GI bleeding symptoms. For access infection: fever, chills, drainage. Do not auto-populate a comprehensive negative ROS.)

Physical Examination

• Vital signs: [BP / HR / RR / SpO2 / Temp] — [hemodynamically stable / unstable]; [afebrile / febrile]
• General/Mental status: [Appearance and distress level]; [Alertness and orientation]; [Sedation or intubation status if applicable]
• Cardiopulmonary: [Heart rhythm and murmurs]; [Lung exam]; [Signs of heart failure or respiratory distress]

Vascular Examination:

• Inspection: [Color, mottling pattern]; [Ulcers or wounds with location and size]; [Bleeding or hematoma]; [Swelling or compartment tenseness]
• Temperature and capillary refill: [Comparative limb temperature]; [Capillary refill time]
• Pulses (bilateral): [Femoral / popliteal / dorsalis pedis / posterior tibial] or [Brachial / radial / ulnar] — [present / diminished / absent]
• Handheld Doppler: [Arterial and venous signals by site]; [Signal quality: triphasic / biphasic / monophasic / absent]
• Neurologic exam: [Sensation by distribution]; [Motor strength by muscle groups]; [Pain with passive stretch if compartment syndrome concern]
• Wound characterization: [Location, size, depth]; [Necrosis or eschar]; [Drainage]; [Infection signs] (Include only if wounds present.)
• Dialysis access exam: [Thrill and bruit quality]; [Aneurysm or pseudoaneurysm]; [Skin integrity and bleeding sites]; [Hand perfusion and neurologic findings for steal] (Include only if evaluating dialysis access.)
• Exam limitations: [Limitations and reason] (State explicitly if exam limited by sedation, pain, cooperation, or dressings.)

Data Reviewed

• Labs: [CBC with Hgb trends, WBC]; [Coagulation: INR, aPTT, anti-Xa]; [BMP and renal function]; [Lactate]; [CK if rhabdomyolysis risk]; [Type and screen status]
• Imaging: [Modality, laterality, date/time, key actionable findings] (If consultant independently reviewed images, note this and summarize findings. If no imaging obtained and management is clinical, state explicitly.)
• Prior records: [Prior operative notes, external records, or imaging reviewed with relevance noted]

Assessment

[Problem 1: Primary consult diagnosis]

• Severity/Urgency: [emergent / urgent / non-urgent] — [Rationale tied to exam and data findings]
• Etiology: [Embolic / thrombotic / acute-on-chronic / iatrogenic / hemorrhagic / infectious]
• Constraints: [Bleeding risk and antithrombotic status]; [Renal function and contrast considerations]; [Anatomic targets and runoff]; [Goals of care and baseline function]
• Limb viability category: [I (viable) / IIa (marginal) / IIb (immediately threatened) / III (irreversible)] — [Based on motor/sensory findings and Doppler] (Include only for ALI.)
• Wound/ischemia/infection severity: [Summary] (Include only for CLTI evaluation.)
• Operative/endovascular candidacy: [Physiological risk]; [Anatomical feasibility]; [Contraindications]; [Patient-centered factors]

[Problem 2]

[Assessment for additional problems if applicable]

Plan

[Problem 1]

• Now: [Immediate actions: anticoagulation decision with rationale; hemostasis measures; NPO status; monitoring frequency for limb checks and labs]
• Next: [Imaging or studies needed with urgency]; [Procedural pathway: OR / endovascular / IR / bedside / conservative]; [Additional workup]
• If-Then: [Escalation criteria and response] (e.g., "If motor deficit progresses or Doppler signals worsen → escalate to emergent intervention.")
• Consults: [Anesthesia, cardiology, nephrology, wound care, ID, IR as needed]
• Disposition: [ICU / step-down / floor]; [Transfer needs]; [Vascular surgery follow-up timing]
• Patient/family communication: [Risks, benefits, alternatives discussed]; [Consent status if procedure planned]

[Problem 2]

[Plan for additional problems if applicable]

Communication

• Recommendations communicated to: [Requesting team/clinician, time, and mode of communication]
• Closed-loop items: [Key actions confirmed with responsible party]
• Urgent notifications: [OR, anesthesia, ICU, or IR contacted and time] (Include only if applicable.)
• Patient/family discussion: [Summary of discussion]; [Interpreter used: yes / no]

Procedure Performed

(Include this section only if a bedside procedure was performed during the consult.)

• Procedure and indication: [Procedure name] for [Indication]
• Consent: [written / verbal / emergency]
• Technique: [Brief description of key steps, equipment, anesthesia]
• Findings and outcome: [Immediate results]; [Complications: none / description]
• Post-procedure plan: [Monitoring instructions, dressing care, medications, follow-up timing]