Peripheral Artery Catheterization Template

[Anytime I mention a balloon or stent size and I say "# by #" sizing, please replace the "by" with a "x" in the note. For example if I say "A 3.5 by 18 mm Orsiro mission stent" please make sure to document it as "A 3.5 x 18 mm Orsiro mission stent"] Patient is a [Patient Age and gender] with a past medical history of [Past Medical History] who presents for peripheral artery angiogram with possible intervention due to [mention clinical reason for intervention]. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Summary: - [Summary of main interventions including lesion percent stenosis, location in vessel, PTA balloon, type of atherectomy, imaging, stent.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List as many summary bullets by separate interventions as needed. After I say "in summary" please summarize that statement and place it here as well, only if I mention "in summary") Procedures Performed: - [Procedure 1] [Vascular access vessel, side, ultrasound guidance] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Only put "ultrasound guided" if it is explicitly mentioned) - [Procedure 2] ([Angiogram, intervention (angioplasty, atherectomy, stenting, imaging)) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - [Procedure 3] ([Vascular access hemostasis, including what vessel, what side] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) (use as many bullet points as needed to comprehensively capture the procedures performed, whether it is vascular access, angiograms, angioplasty, stent deployment, imaging such as IVUS or IFR) Interventions: - Lesion Location: [mention which vessel treated and which segment of it, and what the percent stenosis is] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - Sheath: [mention which sheath the intervention was used for intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - Guide: [mention which guide catheter used for intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - Wire: [mention which wire used for intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - Imaging: [mention if any intracoronary imaging used such as IVUS, or OCT, and mention the details regarding the MLA, MSA and morphology of the lesion] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - PTA Pre: [mention which balloon was used including the size and type] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) -Lithotripsy: [mention if lithotripsy was performed, and designate which type of lithotripsy was performed (shockwave Etc.) and what size balloon was used for lithotripsy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - Atherectomy: [mention if atherectomy was performed, and designate which mode of atherectomy was used such as CSI, laser, rota etc] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - DES: [mention which stent or DES was used including the size and type, even if multiple, list them all] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - PTA Post: [mention which balloon was used including the size and type] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - Stenosis: Pre: [mention the stenosis percentage before intervention] Post: [mention the stenosis percentage after intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) - TIMI grade: Pre: [mention the TIMI grade (0,1,2 or 3) before intervention] Post: [mention the TIMI grade (0,1,2 or 3) before intervention] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely) (Only include if specific details below are mentioned. If there is more than one intervention on separate vessels, please make a separate paragraph for "interventions" for each one with the below included details as well.) Recommendations: - ASA + [anti-platelet medication ordered after intervention besides aspirin (such as brilinta, plavix, effient or integrilin)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Only include if second antiplatelet besides aspirin mentioned) for 12 months; high-intensity statin - IV fluids post-catheterization per Poseidon protocol - Monitor access site above per protocol - Monitor vitals, telemetry, labs with renal function & CBC - Risk factor management with lifestyle modifications - diet, exercise, weight loss, medical compliance - Follow-up in cardiology outpatient clinic in 1 week after discharge with primary cardiologist. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. List as many recommendations as needed.) Peripheral Anatomy: (please mention any other vessels and their anatomy that are mentioned that are not included below) Distal Abdominal Aorta : [mention what the anatomy of the Abdominal aorta is] (only include if mentioned) Right Common Iliac : [mention what the anatomy of the Right Common Iliac is] (only include if mentioned) Right External Iliac : [mention what the anatomy of the Right External Iliac is] (only include if mentioned) Right Common Femoral : [mention what the anatomy of the Right Common Femoral is] (only include if mentioned) Right Profunda : [mention what the anatomy of the Right Profunda is] (only include if mentioned) Right SFA : [mention what the anatomy of the Right SFA is] (only include if mentioned) Right Popliteal : [mention what the anatomy of the Right Popliteal is] (only include if mentioned) Right Tibioperoneal (TP) Trunk : [mention what the anatomy of the Right Tibioperoneal (TP) Trunk is] (only include if mentioned) Right Anterior Tibial (AT) : [mention what the anatomy of the Right Anterior Tibial (AT) is] (only include if mentioned) Right Posterior Tibial (PT) : [mention what the anatomy of the Right Posterior Tibial (PT) is] (only include if mentioned) Right Peroneal: [mention what the anatomy of the Right Peroneal is] (only include if mentioned) Right Dorsalis Pedis: [mention what the anatomy of the Right Dorsalis Pedis is] (only include if mentioned) Right Pedal Arch: [mention what the anatomy of the Right Pedal Arch is] (only include if mentioned) Left Common Iliac : [mention what the anatomy of the Left Common Iliac is] (only include if mentioned) Left External Iliac : [mention what the anatomy of the Left External Iliac is] (only include if mentioned) Left Common Femoral : [mention what the anatomy of the Left Common Femoral is] (only include if mentioned) Left Profunda : [mention what the anatomy of the Left Profunda is] (only include if mentioned) Left SFA : [mention what the anatomy of the Left SFA is] (only include if mentioned) Left Popliteal : [mention what the anatomy of the Left Popliteal is] (only include if mentioned) Left Tibioperoneal (TP) Trunk : [mention what the anatomy of the Left Tibioperoneal (TP) Trunk is] (only include if mentioned) Left Anterior Tibial (AT) : [mention what the anatomy of the Left Anterior Tibial (AT) is] (only include if mentioned) Left Posterior Tibial (PT) : [mention what the anatomy of the Left Posterior Tibial (PT) is] (only include if mentioned) Left Peroneal: [mention what the anatomy of the Left Peroneal is] (only include if mentioned) Left Dorsalis Pedis: [mention what the anatomy of the Left Dorsalis Pedis is] (only include if mentioned) LeftPedal Arch: [mention what the anatomy of the Left Pedal Arch is] (only include if mentioned) "Fares Jamal, DO Interventional Cardiology PGY-7". (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)