Encounter Type (SBC1135):  Arterial Duplex Leg Pseudoaneurysm-Left

Clinical Template ID: 123, Name: Pseudo Aneurysm Narrative (VarID=3846)(Recent Data=0) Pseudo Aneurysm Amount (cc) (VarID=644)(Recent Data=0) Size of Aneurysm (cms) (VarID=645)(Recent Data=0) Physician Injecting (VarID=646)(Recent Data=0) Conclusion (VarID=647)(Recent Data=0) Lookup ID=648 Lookup Name=Pseudo-aneurysm Conclusion Failure Partial success Success 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) Right Lower Limb Pulse Examination Femoral (VarID=93)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Popliteal (VarID=95)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Posterior Tibial (VarID=99)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Dorsalis Pedis (VarID=97)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Trophic Changes muscle atrophy (VarID=301)(Recent Data=0) Loss of Hair (VarID=302)(Recent Data=0) Brittle Nails (VarID=303)(Recent Data=0) Foot Callus (VarID=304)(Recent Data=0) Foot Ulceration (VarID=305)(Recent Data=0) Foot Infection (VarID=306)(Recent Data=0) Trash Foot (VarID=307)(Recent Data=0) Toe(s) Gangrene (VarID=308)(Recent Data=0) Left Lower Limb Pulse Examination Femoral (VarID=94)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Popliteal (VarID=96)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Posterior Tibial (VarID=100)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Dorsalis Pedis (VarID=98)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade 0 1 2 3 4 Trophic Changes Muscle Atrophy (VarID=309)(Recent Data=0) Loss of Hair (VarID=310)(Recent Data=0) Brittle Nails (VarID=311)(Recent Data=0) Foot Callus (VarID=312)(Recent Data=0) Foot Ulceration (VarID=313)(Recent Data=0) Foot Infection (VarID=314)(Recent Data=0) Trash Foot (VarID=315)(Recent Data=0) Toe(s) Gangrene (VarID=316)(Recent Data=0) RiskFactorStatement (VarID=2000034)(Recent Data=0)

Conclusion Template ID: 130, Name: Pesudoaneurysm 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 Pseudo Aneurysm Drug (VarID=695)(Recent Data=0) Lookup ID=637 Lookup Name=Pseudo Aneurysm Thrombosis Agent Other Thrombin Amount (cc) (VarID=644)(Recent Data=0) Size of Aneurysm (cms) (VarID=645)(Recent Data=0) Physician Injecting (VarID=646)(Recent Data=0) Conclusion (VarID=647)(Recent Data=0) Lookup ID=648 Lookup Name=Pseudo-aneurysm Conclusion Failure Partial success Success Right Lower Limb Disease Location (VarID=367)(Recent Data=0) Lookup ID=416 Lookup Name=Lower Limb Disease Location No Disease AortoIliac Fem_Popliteal Tibio-Peroneal Multilevel Ankle Pressure (mm hg) (VarID=150)(Recent Data=0) Ankle Arm Index (VarID=152)(Recent Data=0) Conclusion: (VarID=798)(Recent Data=0) Lookup ID=1019 Lookup Name=Lower Limb conclusion Evidence of graft occlusion Evidence of hemodynamically significant inflow disease Evidence of multilevel occlusion resulting in severe ischemia Evidence of SFA occlusion Evidence of tibioperoneal disease Graft is patent No evidence of hemodynamically significant arterial stenosis. Left Lower Limb Disease Location (VarID=368)(Recent Data=0) Lookup ID=416 Lookup Name=Lower Limb Disease Location No Disease AortoIliac Fem_Popliteal Tibio-Peroneal Multilevel Ankle Pressure (mm hg) (VarID=151)(Recent Data=0) Ankle Arm Index (VarID=153)(Recent Data=0) Conclusion: (VarID=799)(Recent Data=0) Lookup ID=1019 Lookup Name=Lower Limb conclusion Evidence of graft occlusion Evidence of hemodynamically significant inflow disease Evidence of multilevel occlusion resulting in severe ischemia Evidence of SFA occlusion Evidence of tibioperoneal disease Graft is patent No evidence of hemodynamically significant arterial stenosis. 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