Vascular Surgery Consult

Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Follow-up for a persistent cough and reduced energy over the past 10 days.

Assessment:
Symptoms are improving. No red flags identified during today's review.

Plan:
Continue supportive care, review worsening symptoms, and follow up if symptoms do not settle as expected.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Vascular Surgery Consult

History of Present Illness:
(in paragraphs)
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Past Medical History:
(hyphenated list)
- [e.g., Peripheral arterial disease – duration, treatment]
- [e.g., Hypertension – duration, control]
- [Other relevant comorbidities]

Surgical History:
(hyphenated list)
- [Procedure name, date, laterality if applicable]
- [Endovascular interventions – device/type, date]
- [Other vascular or nonvascular surgeries]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Antiplatelet/anticoagulant details]
- [Statins or other relevant therapies]

Allergies:
(hyphenated list)
- [Allergen: reaction]
- [e.g., Contrast media: mild rash]

Family History:
(hyphenated list)
- [Father: condition(s)] 
- [Mother: condition(s)]
- [Siblings: relevant vascular disease]

Social History:
(hyphenated list)
- Tobacco: [status – pack years, quit date]
- Alcohol: [type, amount, frequency]
- Illicit drugs: [type, route]
- Activity level: [baseline walking/gait tolerance]

Physical Exam:
(hyphenated list)
- Vital signs: HR: __ bpm, BP: __/__, T: __ °C/°F, RR: __, O₂ sats: __%
- General: [appearance, distress level]
- Cardiovascular: [heart sounds, murmurs]
- Peripheral vascular:
- Pulses: [e.g., dorsalis pedis, posterior tibial – present/absent]
- Skin: [color, temperature, trophic changes]
- Edema: [grade, location]
- Abdominal: [pulsatile masses, bruits]
- Neurologic: [gross sensory/motor status of limbs]

Investigations:
(hyphenated list)
- Labs:
- [e.g., CBC: WBC __, Hgb __, Plt __]
- [e.g., Coags, renal function]
- Vascular imaging:
- [e.g., Duplex ultrasound – findings]
- [e.g., CT angiogram – stenosis location/severity]
- Other studies: [e.g., Ankle–brachial index]

Assessment & Plan:
(hyphenated list)
- Assessment:
- [Primary vascular diagnosis #1]
- [Secondary findings/co-morbid vascular issues]
- Plan:
- Medical management:
- [e.g., Optimize antiplatelet/anticoagulation]
- [e.g., Statin therapy]
- Procedural plan:
- [e.g., Schedule angioplasty ± stenting – target vessel]
- [e.g., Plan for operative bypass – conduit selection]
- Consults/referrals: [e.g., Interventional radiology, wound care]
- Follow-up:
- [e.g., Re-evaluate in vascular surgery clinic in X weeks]
- [e.g., Repeat ABI or imaging on date]