Encounter Type (SBA1):  Cerebrovascular Duplex Scan

Clinical Template ID: 52, Name: Presentation of Cerebovascular Study Clinical: (VarID=3846)(Recent Data=0) Neck Bruit Right Carotid Bruit (VarID=249)(Recent Data=0) Supraclavicular Bruit (VarID=250)(Recent Data=0) Left Neck Bruit (VarID=251)(Recent Data=0) Supraclavicular Bruit (VarID=252)(Recent Data=0) Pulse Examination Right Superficial Temporal (VarID=89)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Carotid (VarID=91)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Radial (VarID=81)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Left Superficial Temporal (VarID=90)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Carotid (VarID=92)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Radial (VarID=85)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Brachial Blood Pressure Right Systolic (mm Hg) (VarID=101)(Recent Data=0) Diastolic (mm hg) (VarID=104)(Recent Data=0) Left Systolic (mm hg) (VarID=102)(Recent Data=0) Diastolic (mm hg) (VarID=105)(Recent Data=0) RiskFactorStatement (VarID=2000034)(Recent Data=0)

Conclusion Template ID: 133, Name: Cerebrovascular Conclusion Next Followup (VarID=730)(Recent Data=0) Lookup ID=657 Lookup Name=Lab Study Next Followup No follow-up is needed One Week Two Weeks Three Weeks One Month Two Months Three Months Six Months One Year Two Years Findings Summary Right Side: Normal (VarID=776)(Recent Data=0) Maximum Velocity: (VarID=545)(Recent Data=0) Lookup ID=315 Lookup Name=Anatomical Segment Locator Artery .....Thoracic Artery ..........Ascending Aorta ..........Aortic Arch ..........Descending Aorta ..........Right Coronary Artery ..........Left Coronary Artery .....Head & Neck Artery ..........Head & Neck, Right Side Artery ...............Right Posterior Cerebral ....................PCA (P1) ....................Right PCA (P2) ...............Innominate ....................Innominate Artery, Proximal ....................Innominate Artery, Middle ....................Innominate Artery, Distal ...............Right Subclavian ....................Right Proximal Subclavian ....................Right Mid Subclavian ....................Right Distal Subclavian ...............Right Common Carotid ....................Right Proximal Common Carotid ....................Right Mid Common Carotid ....................Right Distal Common Carotid ...............Right Vertebral Artery ....................Right Proximal Vertebral ....................Right Middle Vertebral ....................Right Distal Vertebral ...............Right Internal Carotid Artery Plaque Structure (VarID=131)(Recent Data=0) Lookup ID=154 Lookup Name=Plaque Structure Calcified Heterogenous Homogenous Plaque Surface (VarID=132)(Recent Data=0) Lookup ID=155 Lookup Name=Plaque Surface smooth irregular Diameter Reduction (VarID=130)(Recent Data=0) Left Side: Normal (VarID=777)(Recent Data=0) Maximum Velocity: (VarID=546)(Recent Data=0) Lookup ID=315 Lookup Name=Anatomical Segment Locator Artery .....Thoracic Artery ..........Ascending Aorta ..........Aortic Arch ..........Descending Aorta ..........Right Coronary Artery ..........Left Coronary Artery .....Head & Neck Artery ..........Head & Neck, Right Side Artery ...............Right Posterior Cerebral ....................PCA (P1) ....................Right PCA (P2) ...............Innominate ....................Innominate Artery, Proximal ....................Innominate Artery, Middle ....................Innominate Artery, Distal ...............Right Subclavian ....................Right Proximal Subclavian ....................Right Mid Subclavian ....................Right Distal Subclavian ...............Right Common Carotid ....................Right Proximal Common Carotid ....................Right Mid Common Carotid ....................Right Distal Common Carotid ...............Right Vertebral Artery ....................Right Proximal Vertebral ....................Right Middle Vertebral ....................Right Distal Vertebral ...............Right Internal Carotid Artery Plaque Structure (VarID=144)(Recent Data=0) Lookup ID=154 Lookup Name=Plaque Structure Calcified Heterogenous Homogenous Plaque Surface (VarID=145)(Recent Data=0) Lookup ID=155 Lookup Name=Plaque Surface smooth irregular Diameter Reduction (VarID=143)(Recent Data=0) Critical Findings: Reported to: (VarID=2000001)(Recent Data=0) Reported by: (VarID=2000002)(Recent Data=0) Found time/date: (VarID=2000003)(Recent Data=0) Report time/date: (VarID=2000004)(Recent Data=0) Critical Result (VarID=2000010)(Recent Data=0) Read Back Performed (VarID=2000008)(Recent Data=0)

Risk Factors Template ID: 26, Name: Risk Factors Arteriosclerosis Cardiac Status (VarID=259)(Recent Data=0) LVEF (VarID=709)(Recent Data=0) Unstable Angina (VarID=807)(Recent Data=0) Recent MI (within 30 days) (VarID=808)(Recent Data=0) Carotid Artery Disease (VarID=13)(Recent Data=0) Lookup ID=2000028 Lookup Name=carotid artery di Right .....Right: 1 - 49% .....Right: 50 - 79% .....Right: 80 - 99% .....Right: Occlusion Left .....Left: 1 - 49% .....Left: 50 - 79% .....Left: 80 - 99% .....Left: Occlusion Diabetes (VarID=4)(Recent Data=0) Lookup ID=61 Lookup Name=Diabetes IDDM adult IDDM juvenile NIDDM None Yes Embolization (VarID=297)(Recent Data=0) Lookup ID=403 Lookup Name=Arterial Emolization Multiple Incidents None Single Incident Yes Fibrinogen Level (mg/dl) (VarID=296)(Recent Data=0) Hyperlipidemia (VarID=9)(Recent Data=0) Lookup ID=113 Lookup Name=Hyperlipidemia Yes None Mild Moderate Severe Cholesterol (mg/dl) (VarID=28)(Recent Data=0) LDL (mg/dl) (VarID=26)(Recent Data=0) Triglycerides (mg/dl) (VarID=29)(Recent Data=0) HDL ((mg/dl) (VarID=27)(Recent Data=0) VLDL (%) (VarID=257)(Recent Data=0) History of Irradiation (VarID=382)(Recent Data=0) HIV (VarID=72)(Recent Data=0) Hypertension (VarID=3)(Recent Data=0) Lookup ID=114 Lookup Name=Hypertension Mild Moderate None Severe Yes Hypercoagulable State (VarID=12)(Recent Data=0) Lookup ID=112 Lookup Name=Hypercoagulation None Proven, treated Proven, untreated Suspected Yes Peripheral Arterial Disease (VarID=516)(Recent Data=0) Lookup ID=502 Lookup Name=PAD Amputation Claudication None Rest Pain/Tissue loss Yes Pulmonary Disease (VarID=11)(Recent Data=0) Lookup ID=169 Lookup Name=Pulmonary Status Mild Moderate None Severe Yes Renal Disease (VarID=10)(Recent Data=0) Lookup ID=178 Lookup Name=Renal Mild Moderate None Severe Yes Smoking (VarID=5)(Recent Data=0) Lookup ID=189 Lookup Name=Smoking Mild Moderate None Severe Yes Activity Level (VarID=15)(Recent Data=0) Lookup ID=6 Lookup Name=Activity Level Active Life Style Independent Dependent, Partial Dependent, Complete