Encounter Type (SBE1232):  Venous Duplex Leg Vein Mapping-Right

Clinical Template ID: 56, Name: Presentation Lower Limb Venous Study Narrative (VarID=3846)(Recent Data=0) Right Lower Limb Pain (VarID=350)(Recent Data=0) Edema (VarID=351)(Recent Data=0) Tenderness (VarID=352)(Recent Data=0) Inflammation (VarID=353)(Recent Data=0) Venous Ulcer (VarID=354)(Recent Data=0) Induration (VarID=355)(Recent Data=0) Pigmentation (VarID=327)(Recent Data=0) Varicose Veins (VarID=328)(Recent Data=0) Cyanosis (VarID=329)(Recent Data=0) Circumference Thigh Circumference (cm) (VarID=340)(Recent Data=0) Calf Circumference (cm) (VarID=341)(Recent Data=0) Ankle Circumference (cm) (VarID=342)(Recent Data=0) Left Lower Limb Pain (VarID=330)(Recent Data=0) Edema (VarID=331)(Recent Data=0) Tenderness (VarID=332)(Recent Data=0) Inflammation (VarID=333)(Recent Data=0) Venous Ulcer (VarID=334)(Recent Data=0) Induration (VarID=336)(Recent Data=0) Pigmentation (VarID=337)(Recent Data=0) Varicose Veins (VarID=338)(Recent Data=0) Cyanosis (VarID=339)(Recent Data=0) Circumference Thigh Circumference (cm) (VarID=343)(Recent Data=0) Calf Circumference (cm) (VarID=344)(Recent Data=0) Ankle Circumference (cm) (VarID=345)(Recent Data=0) RiskFactorStatement (VarID=2000034)(Recent Data=0)

Conclusion Template ID: 59, Name: Lower Limb Venous Duplex Outcome 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 Right Lower Limb Positive Duplex (VarID=373)(Recent Data=0) DVT (VarID=374)(Recent Data=0) Lookup ID=203 Lookup Name=Thrombus Age (Venous Duplex) Sub-acute Acute Chronic None Venous Reflux (VarID=375)(Recent Data=0) DVT Outcome (VarID=376)(Recent Data=0) Lookup ID=419 Lookup Name=DVT Duplex Followup N/A Development of Insufficiency Documented Resolution Progression of DVT Conclusion (VarID=766)(Recent Data=0) Lookup ID=1007 Lookup Name=Venous Conclusion No evidence of acute deep venous thrombosis in the lower extremity Acute deep venous thrombosis noted Acute superficial thrombosis noted, with no evidence of acute deep venous thrombosis Chronic deep venous thrombosis noted Deep venous thrombosis of indeterminate age noted Calf veins not imaged due to dressings/bandages Calf veins poorly visualized due to edema Cystic structure noted, popliteal fossa Patient unable to tolerate manual compression maneuvers Calf veins not imaged due to open wounds Proximal thigh vessels not imaged due to line placement Thigh vessels poorly visualized due to edema Left Lower Limb Positive Duplex (VarID=377)(Recent Data=0) DVT (VarID=378)(Recent Data=0) Lookup ID=203 Lookup Name=Thrombus Age (Venous Duplex) Sub-acute Acute Chronic None Venous Reflux (VarID=379)(Recent Data=0) DVT Outcome (VarID=380)(Recent Data=0) Lookup ID=419 Lookup Name=DVT Duplex Followup N/A Development of Insufficiency Documented Resolution Progression of DVT Conclusion (VarID=767)(Recent Data=0) Lookup ID=1007 Lookup Name=Venous Conclusion No evidence of acute deep venous thrombosis in the lower extremity Acute deep venous thrombosis noted Acute superficial thrombosis noted, with no evidence of acute deep venous thrombosis Chronic deep venous thrombosis noted Deep venous thrombosis of indeterminate age noted Calf veins not imaged due to dressings/bandages Calf veins poorly visualized due to edema Cystic structure noted, popliteal fossa Patient unable to tolerate manual compression maneuvers Calf veins not imaged due to open wounds Proximal thigh vessels not imaged due to line placement Thigh vessels poorly visualized due to edema 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: 27, Name: Risk Factors DVT History of DVT (VarID=40)(Recent Data=0) Lookup ID=66 Lookup Name=DVTHistory Yes Multiple None Proven Suspected Immobilization (VarID=38)(Recent Data=0) Post Operative State (VarID=41)(Recent Data=0) History of Malignancy (VarID=35)(Recent Data=0) Lookup ID=134 Lookup Name=Malignancy Yes local or nonrecurrence Metastatic tumor None Regional tumor Adenocarcinoma (VarID=36)(Recent Data=0) Lookup ID=8 Lookup Name=Adenocarcinoma Adenocarcinoma Not adenocarcinoma Cardiac Status (NYHA) (VarID=259)(Recent Data=0) Limb Trauma (VarID=39)(Recent Data=0) Pregnancy (VarID=34)(Recent Data=0) Lookup ID=161 Lookup Name=Pregnancy [DVT RF] Postpartum Absent Present Obesity (VarID=42)(Recent Data=0) Hormonal Treatment (VarID=298)(Recent Data=0) Hypercoagulable State (VarID=12)(Recent Data=0) Lookup ID=112 Lookup Name=Hypercoagulation None Proven, treated Proven, untreated Suspected Yes Hemodialysis Access Location (VarID=78)(Recent Data=0) Lookup ID=260 Lookup Name=Access Location and Conduit Material [AV ACCESS] Placement of lower extremity autogenous AV access Placement of lower extremity non-autogenous AV access Placement of upper extremity autogenous AV access Placement of upper extremity non-autogenous AV access