History, exam and charting

The vascular history

Every vascular history answers three questions: which vascular bed is involved, how threatened the tissue is, and what the patient can tolerate. A short set of core questions belongs in every history, whatever the complaint, because they decide operative risk, the conduit and the medical therapy.

The core questions High yield

Smoking

Current, former or never, with pack-years (packs per day times years smoked) and the quit date, not just "former smoker." Ask about vaping and other tobacco too. Smoking is the strongest modifiable risk factor for PAD and for aneurysm growth and rupture, and continued smoking shortens bypass and stent patency, so every vascular note records it and the cessation help offered.

Diabetes

Type, insulin or oral agents, the most recent hemoglobin A1c, and the end-organ effects: neuropathy (can the patient feel the feet?), retinopathy and nephropathy. Diabetes shifts disease to the tibial vessels, hides ischemic pain behind neuropathy and falsely raises the ABI. Note any SGLT2 inhibitor or GLP-1 receptor agonist, since both carry pre-procedure hold rules.

Kidney function and contrast

Baseline creatinine and eGFR, CKD stage, and dialysis status (modality, schedule, and which arm carries the access). Ask about recent contrast, prior contrast-associated kidney injury, and contrast allergy: what happened, and whether premedication worked. This decides between duplex, CTA and angiography, and how much contrast the team can use.

Cardiac history and functional capacity

Coronary disease, prior MI, coronary stents (when placed and on which antiplatelet), heart failure with the latest ejection fraction, atrial fibrillation and valve disease. Estimate functional capacity in METs: climbing a flight of stairs or walking up a hill without stopping is about 4 METs, the usual threshold in perioperative risk assessment. A claudicant may be stopped by the legs before the heart is ever tested, so ask what limits them.

Prior vascular interventions

Every bypass, endarterectomy, stent, angioplasty, aneurysm repair, dialysis access and amputation: what, which side, when, where and by whom, so the operative notes and angiograms can be found. Then ask about conduit: has the saphenous vein been used? It may have gone to an earlier leg bypass or a coronary bypass, or been stripped or ablated for varicose veins. Look for the scars. The vein that is left often decides which operation is possible.

Antithrombotics, with the last dose

Aspirin, P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel), warfarin, DOACs (apixaban, rivaroxaban, dabigatran, edoxaban, including low-dose rivaroxaban 2.5 mg twice daily used with aspirin in PAD) and cilostazol. Record the indication and the date and time of the last dose. That time decides whether the patient can go to the OR or the angiography suite today, and whether neuraxial anesthesia is an option.

Statin

Name, dose and adherence. Patients with PAD, carotid disease or an aneurysm should be on a high-intensity statin unless there is a documented reason not to be. If they are not, that is a recommendation in your note.

Allergies that matter here

Iodinated contrast; heparin, because a history of HIT changes how the patient is anticoagulated in the OR; the prophylactic antibiotics (penicillin and cefazolin); latex; and chlorhexidine.

Ambulatory and living status

Walks independently, with a cane or walker, uses a wheelchair, or is bedbound. Lives alone, with family, or in a facility, and who helps at home. This is not social filler: whether a patient walks shapes the choice between revascularization and amputation, the amputation level, and the discharge plan.

Goals of care

Code status, the health care decision-maker, and any advance directive. Before a major amputation or a high-risk aortic repair, ask what matters most to the patient (walking again, staying at home, avoiding more operations) and document the conversation and who was present.

Leg pain

Sort the pain into claudication, rest pain or tissue loss before anything else, because that grade drives the decision. Then localize it.

• Claudication. Reproducible cramping, aching or fatigue in a muscle group with walking, relieved within about 10 minutes by standing still. Ask the distance (blocks or meters) and whether it is shrinking, which muscles hurt (buttock and thigh point to aortoiliac disease, the calf to femoropopliteal disease), and what it stops the patient doing. Ask men about erectile dysfunction, part of the Leriche picture.
• Rest pain. Burning pain in the forefoot and toes, not the calf, worse at night or lying flat, and relieved by hanging the foot over the side of the bed or sleeping in a chair. Dependency helps because gravity adds a little perfusion pressure. Ask how long it has been present (CLTI requires more than two weeks) and how the patient sleeps; ankle swelling from sleeping upright is a clue.
• Tissue loss. Any ulcer or gangrene: when it started, what started it, and whether it is healing. A wound that has not healed in two weeks in a patient with PAD is CLTI until shown otherwise.

Other mimics: hip or knee arthritis (pain at the joint, worse with weight bearing, variable from day to day), venous claudication (bursting thigh pain after an old iliofemoral DVT, eased by elevation), painful diabetic neuropathy (burning in a stocking distribution, not relieved by dependency), a symptomatic Baker's cyst, and in a young athlete, popliteal entrapment or chronic exertional compartment syndrome. Many patients have both PAD and spinal stenosis; the history tells you which one is limiting them. See Claudication and CLTI.

The acute limb

• The time of onset. The hour, not the day, or the last time the limb was known to be normal. Ischemic time is what makes muscle unsalvageable.
• Embolus or thrombosis? Embolic sources: atrial fibrillation (and whether anticoagulation was missed or stopped), a recent MI, valve disease, a proximal aneurysm. Thrombotic clues: prior claudication, a prior bypass or stent in that leg, a popliteal aneurysm, and a hypercoagulable state such as cancer or HIT. A sudden, severe onset in a previously normal leg favors embolus; a background of claudication favors thrombosis.
• The six Ps. Pain, pallor, pulselessness, poikilothermia (cold), paresthesia and paralysis. Sensory loss and weakness are the two that grade severity and decide whether there is time for imaging.
• What rules out heparin or lytics. Recent surgery, stroke, bleeding or trauma. Ask too about recent arterial access (a catheterization or an arterial line) and symptoms of aortic dissection.

Then grade the limb with the Rutherford acute ischemia categories, covered in Acute limb ischemia.

Wounds

How long the wound has been there and how it started (a shoe, a fall, a pressure point, a nail trim), whether it hurts (ischemic wounds usually do; neuropathic ones often do not), and whether it is getting better or worse. Ask who has been caring for it (podiatry, a wound clinic, home health), what dressings and offloading have been used, prior debridements, cultures and antibiotics, known osteomyelitis, and prior amputations. Ask about fever, chills and glucose control, which worsen with deep infection. A heel wound in a bedbound patient is a pressure injury until shown otherwise, and painful necrotic skin lesions in a dialysis patient raise calciphylaxis. See The diabetic foot.

Aneurysm

How it was found, and the prior sizes with dates, since growth rate matters as much as diameter. Above all, ask about symptoms: new abdominal, back or flank pain, aneurysm tenderness, or syncope, any of which turns an elective aneurysm into an urgent one. Ask about blue toes (distal embolization), fever or bacteremia (an infected aneurysm), and other aneurysms; a popliteal aneurysm should prompt a look at the aorta and the other knee, and the reverse. Take a family history of aneurysm or dissection in first-degree relatives, and ask about connective tissue disease (Marfan, Loeys-Dietz, vascular Ehlers-Danlos), a bicuspid aortic valve and prior aortic surgery. See Abdominal aortic aneurysm.

Carotid and neurologic

The question that matters is whether the patient is symptomatic: a stroke, TIA or episode of amaurosis fugax in the territory of the diseased carotid, generally within the last six months. Pin down each event.

• What happened. Face, arm or leg weakness or numbness, trouble with speech or language, or transient monocular vision loss, often described as a shade coming down over one eye (amaurosis fugax).
• Laterality. Which side of the body, or which eye. Hemispheric symptoms are contralateral to the carotid lesion (right carotid, left arm); amaurosis is ipsilateral (right carotid, right eye). State whether the side matches the stenosis.
• Timing. The date of the most recent event and how long it lasted. For symptomatic stenosis the benefit of revascularization is greatest within about two weeks of the event, so the date starts the clock.
• Nonfocal symptoms. Dizziness, presyncope or generalized weakness alone are not carotid symptoms. Document them, but do not call the patient symptomatic on their basis.
• Operative factors. Prior neck surgery or radiation, a tracheostomy, cervical spine mobility, and the ability to lie flat. A hostile neck shifts the choice toward stenting. See Carotid disease.

Mesenteric

Chronic mesenteric ischemia is largely a history diagnosis: postprandial abdominal pain beginning roughly 15 to 60 minutes after eating, food fear (eating less to avoid the pain), and unintended weight loss, often after a long negative GI workup. For acute mesenteric ischemia, ask about sudden severe pain out of proportion to the exam, atrial fibrillation or another embolic source, a background of chronic symptoms (acute-on-chronic thrombosis), a hypercoagulable state or recent surgery (mesenteric venous thrombosis), and low-flow states such as heart failure, vasopressors or dialysis (nonocclusive ischemia). Record bowel habits, bloody stool and vomiting. See Mesenteric ischemia.

Venous

For swelling: one leg or both, when it started, and whether it is worse at the end of the day and better with elevation. Ask about heaviness, aching, itching and night cramps, visible varicose veins, skin darkening, and current or prior ulcers. Take a thrombotic history: prior DVT or PE (provoked or unprovoked, what treatment and for how long), prior venous procedures (ablation, stripping, stents), personal or family thrombophilia, cancer, estrogen therapy or pregnancy, and recent surgery, immobility or long travel. Ask about compression and, if it failed, why; a documented trial of compression is often required before a venous procedure. Remember the systemic causes of bilateral swelling (heart, kidney and liver disease, drugs such as amlodipine) and lymphedema. See Venous thromboembolism and Chronic venous insufficiency.

Dialysis access

• Dominant hand. Access usually starts in the nondominant arm, as far distally as the vessels allow.
• Current dialysis. Not yet on dialysis (with the latest eGFR), hemodialysis through a tunneled catheter or an existing access, or peritoneal dialysis. Record the schedule (Monday, Wednesday, Friday or Tuesday, Thursday, Saturday), the dialysis unit and the nephrologist.
• Prior access. Every fistula and graft: side, type, date, how long it worked, and the interventions used to keep it open.
• Central veins. Prior central lines, tunneled catheters, PICCs and ports, and pacemaker or defibrillator leads, any of which can cause central venous stenosis and ruin an arm for access. Arm swelling or chest wall collaterals point the same way.
• Other factors. Heart failure and ejection fraction (an access adds cardiac load), prior arm, breast or axillary surgery, and transplant plans. See Dialysis access.

The focused vascular exam

Examine in the same order every time, compare both sides, and write it down so the next person can tell whether anything has changed. The documented exam is what the team decides on and what the night team compares against.

1. Expose and look. Both legs uncovered from groin to toes, socks off, heels and the spaces between the toes inspected. Note color, scars (prior bypass, vein harvest, sternotomy), amputations, swelling, wounds and dressings.
2. Vital signs with a vascular eye. Rhythm (an irregularly irregular pulse is atrial fibrillation, an embolic source) and blood pressure in both arms. A difference of more than about 15 mmHg suggests subclavian stenosis; use the higher arm for decisions and for the ABI.
3. Palpate the pulses, head to toe. Carotid (gently, one side at a time), brachial and radial, the abdominal aorta for a widened pulsatile mass, the femoral at the midinguinal point, the popliteal with the knee slightly flexed and the fingertips of both hands deep in the fossa, the dorsalis pedis just lateral to the extensor hallucis longus tendon, and the posterior tibial behind the medial malleolus. Feel any bypass graft along its course.
4. Listen. Bruits over the carotids, the abdomen and the femorals, and over any dialysis access.
5. Doppler what you cannot feel. Every nonpalpable pulse gets a handheld Doppler check and a recorded signal.
6. Skin, temperature and capillary refill. Run the back of your hand down both legs to find a temperature change, check capillary refill on the toes, and look for trophic changes.
7. Sensation and motor. Light touch on the dorsum and sole, and toe flexion and extension. In an acute limb these two findings set the Rutherford category; in a diabetic foot, a monofilament test documents neuropathy.
8. Measure when it matters. The ABI, and toe pressures when the vessels are calcified.

The provocative tests (Buerger's test, the Allen test before radial access or harvest) are described in Foundations.

Grading and documenting pulses

Several scales are in use, and the one that matters is the one your team uses. A common one is below; some services use 0 to 4+, with 4+ meaning bounding. Whatever the scale, write each pulse by name and side, and make Doppler-only signals unmistakable so no one reads them as palpable. Many vascular services skip numbers for the foot altogether and write "palpable," "Doppler signal" with its phase, or "absent," which is more reproducible between examiners.

Vascular exam (examined __:__ on __/__)
BP: R arm __/__  L arm __/__   Rhythm: ___
Pulses: 2+ normal, 1+ diminished, 0 absent,
        D = Doppler only (tri / bi / mono)
               R          L
Carotid       ___        ___      Bruit: R __ L __
Brachial      ___        ___
Radial        ___        ___
Aorta         [nonpalpable / normal / widened ___]
Femoral       ___        ___      Bruit: R __ L __
Popliteal     ___        ___
DP            ___        ___
PT            ___        ___
Graft         ___        ___
Doppler sites marked: [Y / N]
ABI           ___        ___   (ankle __ / __ mmHg)
Toe pressure  ___        ___
Temperature   ___        ___
Cap refill    __ s       __ s
Sensation     ___        ___
Motor         ___        ___
Skin: [hair loss / rubor / mottling / edema / ___]
Wound: [site], __ x __ x __ cm, base ___,
  probe-to-bone [+/-], exposed ___,
  cellulitis __ cm beyond edge, drainage ___

Recording Doppler signals

Triphasic

Forward flow in systole, a brief reversal in early diastole, then a small forward wave. The normal signal in a resting peripheral artery.

Biphasic

Forward and reverse components without the third. Often normal in older patients, or a sign of mild disease upstream.

Monophasic

A single, blunted forward signal, often continuing through diastole. Significant disease upstream: the tissue is perfused, but through collaterals.

Absent

No arterial signal. In an acute limb, inaudible pedal arterial signals with an audible venous signal is category II territory, where the sensory and motor exam separates IIa from IIb; losing the venous signal as well marks category III.

Write the artery, the side and the phase: "R PT monophasic Doppler signal, not palpable." Avoid "dopplerable pulses" and "signals present," which say nothing about where or what. A venous signal is a low, continuous rushing sound that varies with breathing and gets louder when you squeeze the calf; an arterial signal beats with the heart. Mistaking one for the other is the classic way a dead foot gets documented as having signals.

The ABI at the bedside

With a manual cuff and a handheld Doppler, measure systolic pressure in both brachial arteries, then at each ankle over both the dorsalis pedis and the posterior tibial, with the cuff just above the malleoli. For each leg, divide the higher of that leg's two ankle pressures by the higher brachial pressure. Record the pressures as well as the ratio, because an ankle pressure under 50 mmHg means something on its own. An ABI of 0.90 or less confirms PAD; above 1.40 the vessels are noncompressible and the ratio is unreliable, so get toe pressures. A toe pressure under 30 mmHg predicts poor wound healing. Full interpretation is in Testing and the ABI.

Skin and trophic changes

• Chronic arterial insufficiency. Hair loss, thin shiny skin, thickened nails, muscle wasting, pallor on elevation with dependent rubor (Buerger's test), and capillary refill slower than about 3 seconds.
• Acute ischemia. A pale or waxy white foot, a level where the temperature drops, and mottling. Mottling that blanches with pressure is still salvageable territory; fixed, nonblanching mottling suggests irreversible ischemia.
• Embolization. Blue toes or livedo with palpable pedal pulses points to atheroembolism from a proximal source such as an aneurysm or a diseased aorta.
• Venous disease. Hemosiderin staining, lipodermatosclerosis, atrophie blanche, eczema and edema, described under the venous exam below.

Describing a wound

Describe the wound so that someone who has never seen it could draw it, and measure rather than estimate. Photographs help, but take and upload them only through the hospital's approved app or workflow.

Location

Precise and anatomic: "plantar first metatarsal head," "tip of the right great toe," "lateral malleolus," "posterior heel."

Size

Length by width by depth in centimeters, with length measured head to toe. Note undermining or tunneling by clock position.

Depth and exposed structures

Skin only, subcutaneous tissue, or down to tendon, joint capsule or bone.

Base

Red granulation, yellow slough, black eschar (dry or wet), or a pale base without granulation, which suggests ischemia.

Probe-to-bone

Positive or negative with a sterile blunt probe. A positive test makes osteomyelitis likely, especially in a diabetic foot.

Edges and surrounding skin

Punched-out, callused, macerated or undermined edges. Cellulitis measured in centimeters beyond the wound edge, plus warmth, induration, fluctuance or crepitus.

Drainage

Amount and character (serous, serosanguineous, purulent) and any odor. Dry versus wet gangrene.

Grading the threatened limb: WIfI

For any patient with rest pain or tissue loss, the note should carry a WIfI grade: Wound, Ischemia and foot Infection, each scored 0 to 3. The three grades combine into a clinical stage from 1 (very low) to 4 (high) that estimates the one-year amputation risk; use the SVS chart or app to stage. The chronic Rutherford categories are in Quick reference.

The neuro exam for carotid patients

Document a baseline before any carotid procedure and repeat it the same way afterward, so a new deficit is recognized as new.

• Hemispheric function. Alertness and orientation, speech and language (fluency, naming, comprehension), facial symmetry, visual fields, pronator drift, and grip, arm and leg strength on both sides. Use the NIH Stroke Scale for any acute deficit.
• Cranial nerves at risk in endarterectomy. Hypoglossal (the tongue deviates toward the injured side), vagus or recurrent laryngeal (hoarseness, a weak cough), the marginal mandibular branch of the facial nerve (an asymmetric lower lip on smiling, which can mimic a central facial droop), and the great auricular nerve (a numb earlobe).

The venous exam

• Examine standing for varicose veins, which can vanish when the patient lies down, and note their distribution (great or small saphenous territory).
• Edema. Pitting or not, how high it reaches, one leg or both. For a suspected DVT, measure calf circumference 10 cm below the tibial tuberosity on both sides; a difference of more than 3 cm is a Wells criterion.
• Skin. Hemosiderin pigmentation, venous eczema, lipodermatosclerosis (woody induration of the lower leg), atrophie blanche, and corona phlebectatica (a fan of small veins at the ankle).
• Ulcers. Venous ulcers sit in the gaiter area, classically above the medial malleolus, and are shallow with irregular edges and a granulating base.
• Arterial check before compression. Feel the pedal pulses or get an ABI before anyone puts compression on the leg.
• Phlegmasia. A massively swollen, painful leg that is white (alba) or blue (cerulea), with threatened arterial inflow, is an emergency.

Document the CEAP clinical class (C0 to C6) for chronic venous disease; the scale is in Quick reference.

The dialysis access exam

Look, feel and listen along the whole access, then check the hand.

Look

Aneurysmal segments and the skin over them (thin, shiny, scabbed or ulcerated skin is a bleeding risk), erythema, arm or hand swelling, and collateral veins over the chest or shoulder, which suggest central stenosis.

Thrill

A healthy fistula has a soft, continuous thrill, strongest at the arterial anastomosis. A thrill present only in systole, or a focal thrill further along the vein, suggests a stenosis.

Pulse

Normally soft and easily compressed. A firm, hyperpulsatile access suggests outflow stenosis; a flat, weak one suggests an inflow problem.

Bruit

Normally low-pitched and continuous through systole and diastole. A high-pitched or systolic-only bruit suggests a stenosis.

Arm elevation test

Raise the arm above the heart. A normal fistula partly collapses; one that stays distended suggests outflow stenosis.

Pulse augmentation test

Occlude the fistula a few centimeters beyond the anastomosis. The pulse between the anastomosis and your finger should strengthen; weak augmentation suggests an inflow problem.

The hand

Color, temperature, capillary refill, the radial pulse, sensation, strength and pain, compared with the other hand, to look for steal. Symptoms that worsen during dialysis are typical of steal.

The consult note

A consult note answers the question asked, grades the threat, and gives recommendations the primary team can act on without calling you to interpret them. It follows the same order as the presentation on Rounds and presenting.

• Restate the question in the first line, and make sure the recommendations answer it.
• Frame the HPI by vascular bed and severity. "Right leg CLTI with tissue loss," not "foot wound."
• Keep the history pertinent. The core questions above, not a transcription of the whole chart.
• Describe imaging as inflow, outflow and target, and say which study is still needed.
• Grade the severity in the assessment: Rutherford and WIfI for chronic limb disease, the Rutherford acute category for an acute limb, symptom status and percent stenosis for carotid disease, diameter and symptoms for an aneurysm.
• Number the recommendations and make each one specific: the drug and dose, the study, the NPO time, and who will place the order.
• Record who staffed it and when, and whether the team will follow or sign off.

Vascular surgery consult note
Seen: __/__ __:__
Requesting: Dr ___, ___ service
Reason for consult: ___

HPI: [age] [M/F] with [risk factors] seen for [question].
Vascular bed: [aortoiliac / fem-pop / tibial / carotid /
  aortic / mesenteric / venous / dialysis access]
Presentation: [claudication at __ blocks / rest pain x __
  wk / tissue loss: ___ / acute, onset __:__ on __/__]
Prior vascular procedures: [what, side, date, where]
  Conduit used: ___   GSV status: R ___  L ___
Pertinent ROS: ___

PMH: CAD/stents ___  CHF (EF __%) ___  AF ___
  DM (A1c __) ___  CKD (Cr __) ___  dialysis ___
  Stroke/TIA ___  COPD ___  other ___
PSH: ___ (incl. CABG, vein harvest, amputations)
Meds: antiplatelet ___ (last dose ___)
  anticoagulant ___ (last dose __/__ __:__)
  statin ___ mg   other relevant ___
Allergies: ___   Contrast: ___   HIT history: [Y/N]
Social: tobacco ___ pk-yr [current / quit __]
  lives [alone / with ___ / facility]
  ambulation [independent / cane / walker / w/c]
Functional capacity: [4+ METs / under 4 / leg-limited]
Code status: ___   Surrogate: ___

Exam
T __  HR __ (rhythm ___)  BP R __/__ L __/__  SpO2 __
General: ___
Heart/lungs: ___
Abdomen: [soft, nontender; aorta ___]
Pulses (2+ / 1+ / 0; D = Doppler only, with phase):
               R          L
Femoral       ___        ___
Popliteal     ___        ___
DP            ___        ___
PT            ___        ___
[carotid / radial / graft as relevant]
Limb: temp ___  cap refill __ s  sensation ___
  motor ___  calf/compartments ___
Wound: [site], __ x __ x __ cm, base ___,
  probe-to-bone [+/-], exposed ___,
  cellulitis __ cm, drainage ___

Data
Labs: Hgb __ Plt __ WBC __ Cr __ K __ INR __
  aPTT __ lactate __ A1c __
ABI: R __ (ankle __ mmHg)   L __ (ankle __ mmHg)
  Toe pressure: R __  L __
Imaging: [study, date]
  Inflow: ___
  Outflow: ___
  Target / runoff: ___
ECG: ___

Assessment
[age] [M/F] with [diagnosis, side], [Rutherford __ /
WIfI W_ I_ fI_ / ALI category __ / symptomatic __%
stenosis / __ cm AAA], [one line on operative risk].

Recommendations
1. ___
2. ___
3. Antithrombotic: ___
4. Statin: ___
5. Tobacco: [counseled / Rx ___ / N/A]
6. Diet: [NPO after midnight for ___ / regular]
Seen and staffed with Dr ___ (attending) at __:__
on __/__. Urgent recommendations discussed with
Dr ___ (primary team) at __:__.
Vascular surgery will [follow daily / sign off].

The admission H&P

Vascular patients come in two ways, and the documentation differs.

Elective

The patient was seen in clinic, the H&P was written there, and the patient arrives on the day of surgery. Before the operation you write or confirm the interval update (see the pre-op checklist note), then the post-operative orders and checks. Some services also write a short admission note after the case.

Urgent

Admitted from the ED, clinic or another hospital with CLTI, an infected foot, acute limb ischemia, a symptomatic aneurysm or a recent TIA. Write a full H&P. If you already wrote the consult note, it is the skeleton: add the full medication reconciliation, family history and review of systems, and an admission plan that covers every active problem, not only the vascular one.

Vascular surgery admission H&P
Admitted: __/__ __:__   Attending: Dr ___
Type: [urgent from ED / clinic / transfer from ___]
Chief complaint: ___
HPI: [framed by vascular bed and severity, as consult]
PMH: ___
PSH: ___ (incl. vascular procedures, vein harvest)
Home meds (reconciled __/__): ___
  Antithrombotics, last dose: ___
  Held on admission: ___
Allergies: ___ (contrast ___, HIT ___)
Social: tobacco ___ pk-yr; alcohol ___; drugs ___
  lives ___; ambulation ___
Family history: [aneurysm / dissection / VTE / ___]
ROS: ___
Exam: [focused vascular exam with pulse grid]
Data: [labs; ECG; imaging as inflow/outflow/target]

Assessment: [one line with severity grade]
Plan
1. Vascular: [procedure ___ on __/__ / workup ___]
2. Antithrombotic: [ASA ___; heparin gtt per protocol /
   ___ held since __/__]
3. Cardiac: [beta-blocker ___; statin ___; ECG ___]
4. Renal: [Cr __; contrast plan ___]
5. Diabetes: [insulin plan ___; A1c __]
6. Infection: [antibiotics ___; cultures ___]
7. VTE prophylaxis: [heparin SQ / on therapeutic
   anticoagulation; no SCD on an ischemic leg]
8. Diet ___   Activity ___   Lines ___
9. Code status ___   Surrogate ___
10. Disposition: [anticipated ___]

Pre-op checklist note

The night before or the morning of an operation, someone confirms that the patient can safely go: paperwork, blood, drugs held or continued, and the planning studies the surgeon will want in the room. On most services that is the intern, and the pre-op note is the record that it was done.

• The H&P is current. Team Under CMS rules the H&P must be done no more than 30 days before surgery (or within 24 hours after admission, but before the operation). If it is older than 24 hours, an update documenting any change in the patient's condition must be written after admission and before surgery. An H&P older than 30 days is redone. Hospital bylaws may be stricter.
• Consent is signed. Operating surgeon or a delegated resident The procedure written in full with side and level and the likely additions ("possible prosthetic graft," "possible angiogram"); risks, benefits and alternatives discussed; blood product consent if separate; an interpreter or a surrogate decision-maker when needed. Students do not obtain surgical consent.
• The site is marked. Operating surgeon or delegate For any procedure with laterality, per the Universal Protocol, with the patient awake and taking part where possible.
• Type and screen or crossmatch. Intern A type and screen for most open cases; crossmatched units for open aortic and redo operations per the attending and blood bank; cell saver requested for open aortic repair. Check the expiry (commonly about 3 days) and the antibody screen, since a positive screen delays crossmatched blood.
• Antiplatelets. Attending decides Aspirin is continued through almost all vascular surgery. Whether a P2Y12 inhibitor continues depends on the operation and why it was started. Never stop dual antiplatelet therapy after a recent coronary stent without cardiology input.
• Anticoagulants held per protocol. Intern, with pharmacy Warfarin is typically stopped about 5 days before, with an INR the day before or the morning of surgery. DOACs are held 1 to 4 days depending on the drug, renal function and bleeding risk. Bridging is rarely needed, and neuraxial anesthesia has longer hold windows. Record the last dose. A heparin drip for acute ischemia often runs into the OR; confirm the stop time with the surgeon and anesthesia.
• Beta-blocker and statin continued. Intern Continue a beta-blocker the patient already takes, but do not start one on the day of surgery. Continue the statin, and start one if it is missing.
• Renal function and the contrast plan. Intern A recent creatinine and potassium. For contrast cases, stop nephrotoxins, give isotonic fluids to patients at risk per protocol, plan to minimize contrast, hold metformin per local policy, and premedicate contrast allergy per protocol. Dialysis patients are usually dialyzed the day before, with a potassium on the morning of surgery.
• Vein mapping. Intern orders Duplex mapping of the great (and if needed small) saphenous veins before a planned bypass, and arm vein and artery mapping before access creation.
• NPO and the diabetes plan. Intern, with anesthesia Fasting per anesthesia guidance (ASA guidance allows clear liquids until 2 hours and a light meal until 6 hours before), though many services still order NPO after midnight. Adjust insulin per protocol. SGLT2 inhibitors are usually held 3 to 4 days before surgery because of euglycemic ketoacidosis; follow current anesthesia guidance for GLP-1 receptor agonists, which has changed recently.
• Antibiotic prophylaxis ordered. Intern Commonly cefazolin (2 g, or 3 g at 120 kg or more) within 60 minutes before incision, or vancomycin started within 120 minutes for a beta-lactam allergy or MRSA colonization; cefazolin redosed every 4 hours or after heavy blood loss, and stopped within 24 hours. Per local protocol.
• Cardiac evaluation. Team, with anesthesia An ECG, and further testing only when it would change management, following the 2024 ACC/AHA perioperative guideline.
• Operation-specific items. Intern Carotid: the baseline neuro exam is documented. Open or complex aortic: a CTV ICU bed requested, blood and cell saver arranged, and the spinal drain decision made (see spinal drains). Endovascular: the device is ordered and in the building. All cases: the CTA, angiogram or vein map is available in the room.

Vascular surgery pre-op note
Procedure: [side] ___   Date: __/__   Surgeon: Dr ___
Diagnosis: ___
H&P: dated __/__; interval update __/__ __:__
Consent: signed __/__ [incl. blood products Y/N]
Site marked: [Y / N/A]
Labs (__/__): Hgb __ Plt __ Cr __ K __ INR __ Glu __
Type and screen: __/__ (expires __/__)
  Crossmatch: __ u PRBC   Cell saver: [Y / N/A]
ECG: ___   Echo: ___   Cardiac eval: ___
Antiplatelet: ASA [continued]; P2Y12 ___ [cont / held]
Anticoagulant: ___ last dose __/__ __:__ [held per ___]
Heparin gtt: [N/A / stop __:__ / continue to OR]
Beta-blocker: [continued / N/A]   Statin: [continued]
Renal: Cr __, eGFR __; contrast plan ___
  [metformin held / fluids per protocol / premed ___]
Vein mapping: [GSV R ___ L ___ / arm veins ___ / N/A]
Imaging for OR: [CTA __/__ / angiogram __/__]
NPO: [after midnight / per anesthesia]; insulin ___
SGLT2i / GLP-1 RA: [N/A / held since __/__]
Antibiotic: [cefazolin __ g / vancomycin] for OR
Post-op bed: [CTV ICU requested / floor / same day]

The brief op note

Write it before the patient leaves the operating room or the PACU, because the full operative report may not be in the chart for hours. The Joint Commission requires this note before transfer to the next level of care when the full report is not yet available.

The required elements are the surgeon and assistants, the procedure, the findings, the estimated blood loss, the specimens and the post-operative diagnosis. A vascular service adds the heparin and protamine, the end-of-case distal exam, implants, and where the patient is going, because those are what the night team and the CTV ICU need. Record the implant details from the implant log rather than from memory.

Brief operative note
Date: __/__
Pre-op diagnosis: ___
Post-op diagnosis: [same / ___]
Procedure: [side, specific: e.g. R CFA to BK popliteal
  bypass with reversed ipsilateral GSV]
Surgeon: Dr ___   Assistant(s): ___
Anesthesia: [general / regional / MAC / local]
Findings: [inflow, outflow, conduit quality; completion
  angiogram or duplex result]
Heparin: ___ units IV at __:__   Last ACT: ___
Protamine: [none / __ mg at __:__]
EBL: __ mL   Cell saver returned: __ mL
Fluids: crystalloid __ mL  PRBC __ u  other ___
UOP: __ mL
Specimens: [none / ___ to pathology / cultures ___]
Drains: [none / ___ in ___]
Implants: [graft, stent, patch, device: type, size]
Complications: [none apparent / ___]
End-of-case exam: R DP __ PT __ | L DP __ PT __
  [graft __; neuro exam ___ for carotid/aortic]
Condition: [stable / ___]
Disposition: [PACU then CTV ICU / floor / home]

The post-op check

A few hours after the patient reaches the floor or the unit, and always before you sign out, see the patient and compare everything with the end of the case. The question is simple: is anything worse than when the patient left the OR?

Patients in the CTV ICU are managed with the intensivists, but the vascular team still checks the limb, the neck or the incision, and the operation-specific problems (see The CTV ICU).

What to focus on, by operation

Carotid endarterectomy or stenting

The neuro exam against the pre-op baseline, the cranial nerves, the neck (hematoma, tracheal deviation, voice, stridor), and blood pressure within the surgeon's target range; both hypotension and hypertension matter. See On call: after carotid surgery.

Open aortic repair

Urine output, hemoglobin, lactate, the abdomen (distension, and bladder pressure if abdominal compartment syndrome is a concern), pulses and motor function in both legs, and the stool, since bloody diarrhea suggests colon ischemia. See On call: after aortic surgery and the CTV ICU by operation.

EVAR or TEVAR

Access sites, distal pulses, creatinine after contrast, and leg strength and sensation, because spinal cord ischemia after thoracic coverage can appear hours later. If a spinal drain is in, its output and pressure per protocol.

Leg bypass or endarterectomy

The graft pulse or signal and the distal signals compared with the end of the case, the incisions (hematoma, lymph leak), and the compartments after revascularizing an acutely ischemic leg.

Endovascular case through the groin or arm

The puncture site (hematoma, bleeding, a new bruit, or back or flank pain suggesting retroperitoneal bleeding), distal pulses, and the bed rest orders for the closure method used. See On call: the groin.

Dialysis access

Thrill and bruit, hematoma, and the hand: color, temperature, sensation, strength and pain.

Amputation

Bleeding through the dressing, pain control, the knee kept straight after a below-knee amputation, and the other foot and both heels, which are at risk in bed.

Vascular surgery post-op check
POD 0 s/p ___ (out of OR __:__)   Seen: __:__
S: Pain __/10 [controlled / not]; [nausea, chest pain,
   dyspnea, new numbness or weakness: ___]
O: T __  HR __ (rhythm ___)  BP __/__ (goal ___)
   RR __  SpO2 __% on ___
   UOP __ mL since OR (__ mL/kg/h); last 2 h __ mL
   Neuro (carotid/aortic): [alert, oriented, speech
   normal, face symmetric, tongue midline, voice
   normal; strength R __ L __; LE motor/sensory ___]
   Neck/incision/groin: [soft, dry, no hematoma / ___]
   Pulses           now          end of case
     R DP           ___          ___
     R PT           ___          ___
     L DP           ___          ___
     L PT           ___          ___
     Graft          ___          ___
   Limb: [warm], cap refill __ s, motor/sensory ___
   Compartments: [soft / ___]
   Drains: __ mL [serosanguineous / ___]
   Spinal drain (if present): __ mL/h, CSF __ mmHg
   Labs: Hgb __ (pre-op __) Plt __ K __ Cr __
     lactate __ glucose __ aPTT/ACT __
A/P: [stable post-op check / concern: ___]
   - ___
   - Discussed with Dr ___ at __:__

The progress note

The daily note reads the way the team thinks: operation and day first, the limb near the top, true numbers, an explicit antithrombotic plan, and a problem-based plan that ends in a disposition. Writing the note explains the reasoning; this is the template.

• POD and operation in the first line. "POD 2 s/p R CFA to BK popliteal bypass with reversed GSV" orients every reader. For a nonoperative patient, use the hospital day and the problem.
• The focused vascular exam high, with the time you did it. Pulses by level, Doppler signals with phase, the incision or wound, and the access site.
• True numbers. Ranges for the last 24 hours, measured urine and drain output, and today's labs.
• Antithrombotics stated outright. Aspirin, statin, the heparin drip rate and whether it is therapeutic, and anything held, with when it restarts.
• A problem-based assessment and plan, tied to inflow, outflow or conduit where it applies, ending with the disposition and a target date.

Vascular surgery progress note
POD __ s/p [side] ___ (__/__) | HD __
[or: HD __, admitted for ___]
Interval/overnight: ___
S: ___ [pain, diet, flatus/BM, ambulation, new sx]
O: Tmax __  HR __-__ (rhythm ___)  BP __-__/__-__
   SpO2 __% on ___
   I/O 24 h: __ in / __ out   UOP __ mL
   Drains: __ mL [character]
   Vascular exam (examined __:__):
     Pulses: R DP __ PT __ | L DP __ PT __ | graft __
     Limb: [warm / cool], cap refill __ s, motor/sens ___
     Incision: ___
     Wound: [site], __ x __ cm, base ___, drainage ___
     Access site: ___
   Other exam: ___
   Labs: Hgb __ Plt __ WBC __ Cr __ K __ Mg __
     aPTT / anti-Xa __ INR __
   Imaging/studies: ___
   Antithrombotics: ASA [Y/N]  statin [Y/N]
     Heparin gtt: [N/A / __ units/h, therapeutic Y/N]
     Held: ___ since __/__, restart ___
A/P: [age] [M/F] POD __ s/p ___ for ___, [stable / ___]
1. [Vascular problem]: ___
2. Antithrombotic: ___
3. ___
4. ___
VTE prophylaxis: ___   Diet: ___
Activity / PT / OT: ___   Lines/drains: ___
Dispo: [home / home health / SAR / SNF], target __/__

Discharge summary and instructions

The discharge summary is the note the next doctor reads: the primary care physician, the nursing facility, the emergency physician who sees the patient in two weeks. For a vascular patient it must carry the antithrombotic plan and the surveillance plan, because those are what get lost.

The procedure

Each operation or intervention with the date, side, conduit or device, and any complication. "Right CFA to below-knee popliteal bypass with reversed ipsilateral GSV" is useful; "bypass" is not.

Antiplatelet and statin

Name and dose. If either is missing, say why (true allergy, intolerance, bleeding); otherwise the next physician will assume it was an oversight, or never notice.

Anticoagulation

Agent, dose (including any loading phase), indication, planned duration, and who monitors it. Say explicitly whether aspirin continues alongside it, and if anticoagulation was stopped, say so and why.

Wound care

Dressing instructions, when the patient may shower, no soaking until healed, when staples or sutures come out and who removes them, and any negative pressure wound therapy settings and home health orders.

Activity

Weight-bearing status (protecting a fresh amputation or a heel wound), lifting limits after open abdominal surgery, driving (not on opioids, and not until the patient can brake safely), and leg elevation for post-bypass swelling.

Follow-up and surveillance

The clinic visit and the study that goes with it, named precisely. Typical SVS-based intervals: a vein bypass gets a duplex at about 1 month, then around 3, 6 and 12 months, then yearly; after EVAR, a CTA at about 1 month, then yearly imaging (often duplex) if there is no endoleak and the sac is stable; after carotid endarterectomy, a baseline duplex within the first few months, then periodic surveillance; after open aortic repair, imaging about every 5 years. Follow your attending's protocol and write the study and the interval.

Smoking cessation

Counseling given, pharmacotherapy prescribed (nicotine replacement, varenicline), and a referral to a quitline or cessation program. Continued smoking lowers graft patency and raises amputation risk.

Return precautions

Specific to the operation: a cold, pale, numb or weak foot; increasing leg pain; wound redness, drainage or fever; groin swelling or bleeding; and after carotid surgery, new weakness, numbness, speech or vision change, which means calling 911.

Procedure(s): __/__ [side] ___ [conduit / device]
Findings / complications: ___
Hospital course by problem:
1. ___
2. ___
Discharge antithrombotics:
  Antiplatelet: ___    Statin: ___ mg
  Anticoagulant: ___ dose ___ for ___ (indication)
    Duration: ___   Monitored by: ___
Held meds and restart dates: ___
Wound: [care ___; shower from __/__; no soaking
  until healed]; staples/sutures out __/__ by ___
Activity: [weight bearing ___; no lifting over __ lb
  for __ wk; no driving on opioids; elevate legs ___]
Tobacco: [never / quit / counseled, Rx ___]
Follow-up: vascular clinic in __ wk with [study]
  Surveillance plan: ___
Pending at discharge: ___ (follow-up by ___)
Return precautions: [cold, pale, numb or weak foot;
  wound redness, drainage or fever; groin swelling
  or bleeding; carotid: new weakness, speech or
  vision change, call 911]
Disposition: [home / home health / SAR / SNF]

Before the patient leaves

• Antiplatelet and statin prescribed. Or the reason they are not is documented.
• Anticoagulation plan written. Drug, dose, duration and who manages it, with the first INR or lab check booked if needed.
• Medication reconciliation complete. Every held drug restarted or given a restart date: anticoagulants, metformin after contrast, antihypertensives held for low blood pressure.
• Wound plan and supplies arranged. Dressings, negative pressure wound therapy, home health or wound clinic, and a staple or suture removal date.
• Follow-up booked and imaging ordered. Clinic visit and surveillance study on the same day where possible.
• Activity and weight bearing written. Therapy recommendations (PT, OT, equipment) acted on.
• Smoking cessation addressed. Counseling documented and pharmacotherapy offered.
• Return precautions taught back. The patient can say which symptoms mean calling the clinic and which mean calling 911.
• Pending results assigned. Cultures, pathology and any study still out, with the person responsible for following them up.
• Disposition and handoff complete. Home, home with services, rehab or skilled nursing, and the summary sent to the primary care physician and any facility.

Working faster in PowerChart

The hospital runs on Cerner PowerChart (Cerner is now part of Oracle Health). Most of the time saved on a busy service comes from a handful of features used well. Names and layouts vary with each hospital's build, so treat this as a map of what exists, not click-by-click instructions. Logging in and first-day setup are on Your first day.

Patient lists

The service may already have a shared team list. Build a custom list of the patients you follow as well, so pre-rounding starts from one screen, and add each consult the moment you get the page.

Results Review and flowsheets

Labs, vitals and other results laid out by time. Set the date range to the last 24 to 72 hours, and use the trend or graph view for hemoglobin, platelets and creatinine rather than reading single values.

iView Interactive View and I&O

Where nursing documents vitals, intake and output, drain output, neuro checks and pulse checks. This is where you see what the nurse heard on the Doppler at 3 a.m. and how the urine output ran hour by hour.

The MAR

The medication administration record shows what was actually given and when, which is not always what was ordered: whether the heparin drip was running or paused, when the last anticoagulant dose went in, how much PRN opioid the patient needed.

Orders and PowerPlans

PowerPlans are PowerChart's order sets: grouped orders for a situation such as post-operative care, a heparin nomogram or a contrast study. Save orders you place often to your favorites.

Dynamic Documentation

The usual note-writing tool. Note templates can pull vitals, labs, medications and I&O into the note automatically; check what each one pulls and over what time window. Some builds still use older structured PowerNote templates.

Auto Text

Personal shortcut phrases: type a short abbreviation and it expands into a block of text. Personal Auto Text is yours to create and edit; shared phrases may also exist.

Message Center

The inbox: results to review, notes to sign or forward for co-signature, and messages. Unsigned notes and co-signature requests wait here until you act on them.

The handoff tool

An electronic sign-out, usually organized along I-PASS lines, where the build includes one. Update the one-liner, the active issues and the "if this, then that" plan for each patient before you leave.

Habits that save time

• Let templates pull data, never the exam. Auto-populated vitals, labs and medications are fine once you have checked them. The exam, the wound and the plan are typed fresh every day. Never copy forward an exam.
• Check iView before you see a post-op patient. The overnight pulse checks and urine output tell you what to look at first.
• Read the source documents. For a returning patient, open the prior operative note and angiogram report rather than relying on the last progress note; filter the documents view by note type to find them.
• Check the MAR before you write the antithrombotic plan. "On heparin" in yesterday's plan does not mean the drip ran overnight.
• Clear Message Center daily. Unsigned notes and co-signature requests go stale quickly.