Encounter Type (SBC2122):  Upper Limb Arterial Duplex, Incomplete or Unilateral

Clinical Template ID: 624, Name: 0_Presentation of Upper 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) Activity Level (VarID=15)(Recent Data=0) Lookup ID=6 Lookup Name=Activity Level Active Life Style Dependent, Complete Dependent, Partial Independent Cardiac Disease (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 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 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 Hormonal Treatment (VarID=298)(Recent Data=0) 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 Previous CVA (VarID=5311)(Recent Data=0) 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 Recent unexplained weight loss (VarID=5306)(Recent Data=0) Smoking (VarID=5)(Recent Data=0) Lookup ID=189 Lookup Name=Smoking Yes No Active Former PPD yrs 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 Upper Limb Cyanosis (VarID=5651)(Recent Data=0) Muscle atrophy (VarID=5652)(Recent Data=0) Deformity (VarID=5653)(Recent Data=0) Swelling (VarID=5654)(Recent Data=0) Rubor (VarID=5659)(Recent Data=0) Gangrene (VarID=5660)(Recent Data=0) Infection (VarID=5661)(Recent Data=0) Pulse Rt Axillary (VarID=84)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Rt Brachial (VarID=83)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Rt Radial (VarID=81)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Rt Ulnar (VarID=82)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Allen Test (VarID=255)(Recent Data=0) Lookup ID=265 Lookup Name=Allen Test [AV ACCESS] Negative (Normal) Positive Left Upper Limb Cyanosis (VarID=5655)(Recent Data=0) Muscle atrophy (VarID=5656)(Recent Data=0) Deformity (VarID=5657)(Recent Data=0) Swelling (VarID=5658)(Recent Data=0) Rubor (VarID=5662)(Recent Data=0) Gangrene (VarID=5663)(Recent Data=0) Infection (VarID=5664)(Recent Data=0) Pulse Lt Axillary (VarID=88)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Lt Brachial (VarID=87)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Lt Radial (VarID=85)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Lt Ulnar (VarID=86)(Recent Data=0) Lookup ID=263 Lookup Name=Clinical Pulse Grade Diminished Healthy Absent Allen Test (VarID=256)(Recent Data=0) Lookup ID=265 Lookup Name=Allen Test [AV ACCESS] Negative (Normal) Positive Previous Surgeries Previous extremity arterial procedure (VarID=5301)(Recent Data=0) Surgery (VarID=5302)(Recent Data=0) Endovascular (VarID=5303)(Recent Data=0) 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 Upper Limb Arterial Title (VarID=5165)(Recent Data=0) Right Pulse Examination (VarID=4659)(Recent Data=0) Right Hand Allen Test (VarID=4669)(Recent Data=0) Left Upper Limb Arterial Title (VarID=5166)(Recent Data=0) Left Pulse Examination (VarID=4660)(Recent Data=0) Left Hand Allen Test (VarID=4670)(Recent Data=0) Previous Arterial Surgeries (VarID=5400)(Recent Data=0)

Conclusion Template ID: 655, Name: 0_Upper Limb Arterial Study Findings Summary Right Side: Right Arm-Left Arm Brachial Index (VarID=5408)(Recent Data=0) Wrist Pressure (mm hg) (VarID=4921)(Recent Data=0) WBI (VarID=169)(Recent Data=0) Segmental Pressure Brachial Index Impression (VarID=5354)(Recent Data=0) Lookup ID=2209 Lookup Name=Upper Limb Segmental Pressures - Brachial Impression (UMMC) Normal Mild inflow stenosis Significant inflow stenosis Radial Index Impression (VarID=5356)(Recent Data=0) Lookup ID=2210 Lookup Name=Upper Limb Segmental Pressures - Radial/Ulnar Impression (UMMC) Normal Mild Stenosis Significant Stenosis Ulnar Index Impression (VarID=5359)(Recent Data=0) Lookup ID=2210 Lookup Name=Upper Limb Segmental Pressures - Radial/Ulnar Impression (UMMC) Normal Mild Stenosis Significant Stenosis Allen Test (VarID=255)(Recent Data=0) Lookup ID=265 Lookup Name=Allen Test [AV ACCESS] Negative (Normal) Positive Conclusion (VarID=780)(Recent Data=0) Lookup ID=1013 Lookup Name=Upper Limb Arterial Study Axillary artery stenosis Brachial Artery Stenosis No evidence of hemodynamically significant arterial stenosis. Radial Artery Stenosis Ulnar Artery Stenosis Left Side: Left Arm-Right Arm Brachial Index (VarID=5409)(Recent Data=0) Wrist Pressure (mm hg) (VarID=4922)(Recent Data=0) WBI (VarID=168)(Recent Data=0) Segmental Pressure Brachial Index Impression (VarID=5355)(Recent Data=0) Lookup ID=2209 Lookup Name=Upper Limb Segmental Pressures - Brachial Impression (UMMC) Normal Mild inflow stenosis Significant inflow stenosis Radial Index Impression (VarID=5357)(Recent Data=0) Lookup ID=2210 Lookup Name=Upper Limb Segmental Pressures - Radial/Ulnar Impression (UMMC) Normal Mild Stenosis Significant Stenosis Ulnar Index Impression (VarID=5359)(Recent Data=0) Lookup ID=2210 Lookup Name=Upper Limb Segmental Pressures - Radial/Ulnar Impression (UMMC) Normal Mild Stenosis Significant Stenosis Allen Test (VarID=256)(Recent Data=0) Lookup ID=265 Lookup Name=Allen Test [AV ACCESS] Negative (Normal) Positive Conclusion (VarID=781)(Recent Data=0) Lookup ID=1013 Lookup Name=Upper Limb Arterial Study Axillary artery stenosis Brachial Artery Stenosis No evidence of hemodynamically significant arterial stenosis. Radial Artery Stenosis Ulnar Artery Stenosis Pseudoaneurysm Neck Width (cm) (VarID=5351)(Recent Data=0) Neck Length (cm) (VarID=5352)(Recent Data=0) Neck Diameter (cm) (VarID=5353)(Recent Data=0) 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)