Encounter Type (SBC14):  Lower Limb Arterial Evaluation/Treadmill Exercise Study

Clinical Template ID: 618, Name: 0_Presentation of Lower Limb Arterial Study Study Type (VarID=5668)(Recent Data=0) Lookup ID=2248 Lookup Name=Other Study Types Follow-up for Angio Intraoperative Study Non-billable On call - after hours Portable Research Teaching Operative History Procedure (VarID=5076)(Recent Data=0) Date (VarID=5077)(Recent Data=0) Side (VarID=5078)(Recent Data=0) Lookup ID=168 Lookup Name=Procedure Side N/A Right Left Bilateral Group (VarID=5691)(Recent Data=0) Risk Factors Age (VarID=258)(Recent Data=0) 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) Atrial Fibrillation (VarID=4548)(Recent Data=0) Carotid Artery Disease (VarID=13)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Diabetes (VarID=4)(Recent Data=0) Lookup ID=61 Lookup Name=Diabetes IDDM adult IDDM juvenile NIDDM No Yes Hyperlipidemia (VarID=9)(Recent Data=0) Lookup ID=113 Lookup Name=Hyperlipidemia None Mild Moderate Severe Yes History of Irradiation (VarID=3982)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes HIV (VarID=72)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Hypertension (VarID=3)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Hypercoagulable State (VarID=12)(Recent Data=0) Lookup ID=112 Lookup Name=Hypercoagulation No Proven, treated Proven, untreated Suspected Yes Peripheral Arterial Disease (VarID=516)(Recent Data=0) Lookup ID=502 Lookup Name=PAD Amputation Claudication No Rest Pain/Tissue loss Yes Pulmonary Disease (VarID=11)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Renal Disease (VarID=10)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Smoking (VarID=5)(Recent Data=0) Lookup ID=189 Lookup Name=Smoking Yes No Active Former PPD yrs Unexplained recent weight loss (VarID=5306)(Recent Data=0) Hormonal Treatment (VarID=298)(Recent Data=0) Previous CVA (VarID=5311)(Recent Data=0) on corticosteroids (VarID=5741)(Recent Data=0) Clinical Brachial Pressure: Rt Systolic (mm hg) (VarID=101)(Recent Data=0) Rt Diastolic (mm hg) (VarID=104)(Recent Data=0) Lt Systolic (mm hg) (VarID=102)(Recent Data=0) Lt Diastolic (mm hg) (VarID=105)(Recent Data=0) Right Lower Limb Pulse Examination Rt Femoral (VarID=93)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Rt Popliteal (VarID=95)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Rt Posterior Tibial (VarID=99)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Rt Dorsalis Pedis (VarID=97)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Rt Trophic Changes (VarID=4683)(Recent Data=0) 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) Rt Foot Ulceration (VarID=305)(Recent Data=0) Lookup ID=2000003 Lookup Name=Ulceration no yes calf ankle foot (dorsal) foot (plantar) digit #1 digit #2 digit #3 digit #4 digit #5 Rt Foot Infection (VarID=306)(Recent Data=0) Rt Trash Foot (VarID=307)(Recent Data=0) Rt Toe(s) Gangrene (VarID=308)(Recent Data=0) Lookup ID=2000004 Lookup Name=Gangrene no yes foot digit #1 digit #2 digit #3 digit #4 digit #5 Rt Lower Limb Amputation (VarID=5405)(Recent Data=0) Lookup ID=133 Lookup Name=Lower Limb Status Above knee Below Knee High Thigh Hip disarticulation Intact Knee disarticulation Nonanatomic (Foot) Syme's Toe(s) Transmetatarsal Left Lower Limb Pulse Examination Lt Femoral (VarID=94)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Lt Popliteal (VarID=96)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Lt Posterior Tibial (VarID=100)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Lt Dorsalis Pedis (VarID=98)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Lt Trophic Changes (VarID=4684)(Recent Data=0) 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) Lt Foot Ulceration (VarID=313)(Recent Data=0) Lookup ID=2000003 Lookup Name=Ulceration no yes calf ankle foot (dorsal) foot (plantar) digit #1 digit #2 digit #3 digit #4 digit #5 Lt Foot Infection (VarID=314)(Recent Data=0) Lt Trash Foot (VarID=315)(Recent Data=0) Lt Toe(s) Gangrene (VarID=316)(Recent Data=0) Lookup ID=2000004 Lookup Name=Gangrene no yes foot digit #1 digit #2 digit #3 digit #4 digit #5 Lt Lower Limb Amputation (VarID=5406)(Recent Data=0) Lookup ID=133 Lookup Name=Lower Limb Status Above knee Below Knee High Thigh Hip disarticulation Intact Knee disarticulation Nonanatomic (Foot) Syme's Toe(s) Transmetatarsal Generate Note Options Include Operative History Note (VarID=5684)(Recent Data=0) Include Risk Factor Note (VarID=5679)(Recent Data=0) Clinical Note (VarID=5680)(Recent Data=0) Statements Procedure List Title (VarID=5632)(Recent Data=0) Procedure List All (VarID=5075)(Recent Data=0) Risk Factors Title (VarID=5633)(Recent Data=0) Risk Factors Note (VarID=5074)(Recent Data=0) Clinical Title (VarID=5634)(Recent Data=0) Blood Pressure (VarID=4651)(Recent Data=0) Right Lower Limb Arterial Title (VarID=5163)(Recent Data=0) Right Trophic Changes (VarID=4662)(Recent Data=0) Right Pulse Examination (VarID=4659)(Recent Data=0) Right Foot Examination (VarID=4664)(Recent Data=0) Right Lower Limb Amputation Statement (VarID=5412)(Recent Data=0) Left Lower Limb Arterial Title (VarID=5164)(Recent Data=0) Left Trophic Changes (VarID=4663)(Recent Data=0) Left Pulse Examination (VarID=4660)(Recent Data=0) Left Foot Examination (VarID=4665)(Recent Data=0) Left Lower Limb Amputation Statement (VarID=5413)(Recent Data=0) Previous Arterial Surgeries (VarID=5400)(Recent Data=0)

Conclusion Template ID: 644, Name: 0_Lower Limb Arterial Physiological Findings Summary 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 results (VarID=4743)(Recent Data=0) Critical Result Type (VarID=5650)(Recent Data=0) Lookup ID=2243 Lookup Name=Lab Critical Result Type Arteriovenous fistula DVT Highest Limb ABI < .40 ICA Critical Stenosis Mesenteric artery critical stenosis Pseudoaneurysm Renal artery critical stenosis Reported To (VarID=3996)(Recent Data=0) Reported by (VarID=3995)(Recent Data=0) Found Time (VarID=3994)(Recent Data=0) Reported Time (VarID=3998)(Recent Data=0) Reporting Method (VarID=4544)(Recent Data=0) Lookup ID=1992 Lookup Name=Reporting Method email Fax Phone Publish to EMR Free-Text Note (VarID=5307)(Recent Data=0) 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

Risk Factors Template ID: 26, Name: Risk Factors Arteriosclerosis Age (VarID=258)(Recent Data=0) Age Group (VarID=37)(Recent Data=0) Lookup ID=9 Lookup Name=Age >= 80 < 55 55 - 69 70 - 79 Carotid Artery Disease (VarID=13)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Cardiac Status (SVS) (VarID=2)(Recent Data=0) Lookup ID=23 Lookup Name=ASHD Mild Moderate None Severe Yes Diabetes (VarID=4)(Recent Data=0) Lookup ID=61 Lookup Name=Diabetes IDDM adult IDDM juvenile NIDDM No Yes Embolization (VarID=297)(Recent Data=0) Lookup ID=403 Lookup Name=Arterial Emolization Multiple Incidents No Single Incident Yes Fibrinogen Level (mg/dl) (VarID=296)(Recent Data=0) Hyperlipidemia (VarID=9)(Recent Data=0) Lookup ID=113 Lookup Name=Hyperlipidemia None Mild Moderate Severe Yes 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=3982)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes HIV (VarID=72)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Hypertension (VarID=3)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Hypercoagulable State (VarID=12)(Recent Data=0) Lookup ID=112 Lookup Name=Hypercoagulation No Proven, treated Proven, untreated Suspected Yes Peripheral Arterial Disease (VarID=516)(Recent Data=0) Lookup ID=502 Lookup Name=PAD Amputation Claudication No Rest Pain/Tissue loss Yes Pulmonary Status (VarID=11)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Renal Disease (VarID=10)(Recent Data=0) Lookup ID=2000002 Lookup Name=Carotid Artery Disease VCU no yes Smoking (VarID=5)(Recent Data=0) Lookup ID=189 Lookup Name=Smoking Yes No Active Former PPD yrs Weight (Kg) (VarID=33)(Recent Data=0)