| 1 | English French Notes Complete/Exclude
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| 2 | BURNING ON URINATION:
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| 3 | LOW RED BLOOD COUNT:
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| 4 | KIDNEY PROBLEMS:
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| 5 | Females Only:
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| 6 | PREGNANT:
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| 7 | Males Only:
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| 8 | DISCHARGE FROM PENIS:
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| 9 | IMPOTENCE:
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| 10 | OTHER:
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| 11 | RASH/ULCERS ON PENIS:
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| 12 | PATIENT LABORATORY INFORMATION
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| 13 | Aldolase
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| 14 | Anti-DNA Antibody
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| 15 | Anti-skeletal muscle
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| 16 | Alkaline phosphatase
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| 17 | Anti-RNP
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| 18 | Urea nitrogen
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| 19 | Hepatitis B Antibody
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| 20 | Hepatitis B Antigen
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| 21 | Cholesterol
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| 22 | Complement CH50
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| 23 | Cryoglobulins
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| 24 | Creatinine
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| 25 | Complement
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| 26 | Glucose
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| 27 | Complement C4
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| 28 | HLA B27
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| 29 | Bilirubin, total
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| 30 | Latex fixation
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| 31 | Protein, total
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| 32 | Uric acid
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| 33 | Salicylate
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| 34 | UR Glucose
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| 35 | UR Protein
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| 36 | RBC/HPF
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| 37 | WBC/HPF
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| 38 | Granular/cast/lpf
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| 39 | Choloride
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| 40 | WBC/CASTS/LPF
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| 41 | Bicarbonate
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| 42 | Creatinine Clearance
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| 43 | Neutrophil
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| 44 | Bands
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| 45 | Lymphs
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| 46 | Monocytes
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| 47 | Eosino
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| 48 | Baso
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| 49 | Platelet
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| 50 | Reticulocytes
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| 51 | Westergren ESR
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| 52 | Protrhombin time
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| 53 | Partial thromboplastin
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| 54 | NARRATIVE HISTORY
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| 55 | Physical Examination
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| 56 | General:
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| 57 | LYMPH NODE ENLARGEMENT:
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| 58 | UVEITIS/IRITIS:
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| 59 | MUSCLE TENDERNESS:
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| 60 | CONJUNCTIVITIS/EPISCLERITIS:
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| 61 | MUSCLE WEAKNESS-DISTAL:
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| 62 | CATARACT:
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| 63 | MUSCLE WEAKNESS-PROXIMAL:
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| 64 | ORAL ULCERS:
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| 65 | MUSCLE ATROPHY
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| 66 | RALES:
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| 67 | PSYCHOSIS:
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| 68 | PLEURAL RUB/
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| 69 | CLINICAL PLEURISY:
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| 70 | ORGANIC BRAIN SYNDROME:
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| 71 | PLEURAL EFFUSION:
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| 72 | MOTOR NEUROPATHY:
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| 73 | PERICARDIAL RUB/PERICARDITIS:
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| 74 | SENSORY NEUROPATHY:
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| 75 | CUTANEOUS VASCULTITIS:
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| 76 | RASH-MALAR:
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| 77 | PALPABLE PUPURA:
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| 78 | RASH-DISCOID:
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| 79 | SKIN ULCERS:
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| 80 | RASH-JRA:
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| 81 | ERYTHEMA NODOSUM:
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| 82 | RASH-SLE,NON-MALAR:
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| 83 | PERIUNGAL ERYTHEMA:
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| 84 | RASH-OTHER:
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| 85 | HELIOTROPE EYELIDS:
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| 86 | KNUCKLE ERYTHEMA:
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| 87 | TELANGIECTASIS:
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| 88 | SUBCUTANEOUS CALCIFICATIONS:
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| 89 | SCLERODACTYLY:
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| 90 | KERATODERMIA BLENNORRHAGICA:
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| 91 | SCLERODERMA-EXTREMITY:
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| 92 | DACTYLITIS:
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| 93 | SCLERODERMA-GENERALIZED:
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| 94 | NAIL PITTING:
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| 95 | MORPHEA:
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| 96 | PSORIASIS:
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| 97 | DIGITAL ULCERS:
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| 98 | HEEL PAIN:
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| 99 | HEALTH ASSESSMENT
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| 100 | Questionnaire date:
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| 101 | Study status:
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| 102 | Drug Study:
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| 103 | Dressing and Grooming:
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| 104 | Arising:
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| 105 | Eating:
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| 106 | Walking:
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| 107 | Hygiene:
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| 108 | Reach:
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| 109 | Activities:
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| 110 | Pain Scale:
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| 111 | II. CLINICAL DATA
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| 112 | Sex
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| 113 | Age
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| 114 | NYHA functional class
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| 115 | Creatinine
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| 116 | III. CARDIAC CATHETERIZATION AND ANGIOGRAPHIC DATA
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| 117 | LVEDP
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| 118 | Lv Contraction Score (from contrast or
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| 119 | Aortic systolic pressure
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| 120 | radionuclide angiogram or 2D echo)
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| 121 | *PA systolic pressure
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| 122 | *PAW mean pressure
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| 123 | Grade Ejection Fraction Definition
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| 124 | *patients having right heart cath.
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| 125 | Range
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| 126 | Percent left main stenosis
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| 127 | Number of other major coronary
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| 128 | arteries (LAD,right with PDA,
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| 129 | circumflex with marginals)
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| 130 | with stenosis(es) => 50%
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| 131 | IV. OPERATIVE RISK SUMMARY DATA
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| 132 | Physician's preoperative
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| 133 | estimate of operative
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| 134 | V. OPERATIVE DATA
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| 135 | CABG distal anastomoses:
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| 136 | number with vein
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| 137 | number with IMA
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| 138 | Great vessel repair requiring
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| 139 | Other(not checked above)
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| 140 | Date of death
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| 141 | Renal failure requiring
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| 142 | Repeat cardiopulmonary
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| 143 | Repeat Cardiopulmonary
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| 144 | TIME TEST:
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| 145 | AGE:
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| 146 | WT LBS:
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| 147 | REF PHYS:
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| 148 | ETT PROTOCOL:
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| 149 | HYPERVENTILATION:
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| 150 | TARGET HR:
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| 151 | RESTING EKG:
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| 152 | ONSET CP
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| 153 | PEAK EX
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| 154 | SBP/DBP
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| 155 | ST/SLP
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| 156 | RPP/1000
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| 157 | MIN:SEC
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| 158 | PEAK MPH:
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| 159 | % TARGET HR:
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| 160 | TIME ST SEGMENT RETURN TO BASELINE:
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| 161 | SIGNIFICANT ARRHYTHMIAS:
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| 162 | BLOOD PRESSURE CHANGES:
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| 163 | OTHER EKG CHANGES:
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| 164 | COMPLICATIONS:
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| 165 | EKG TECH:
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| 166 | ATTN PHYS:
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| 167 | -------------------------------VENTRICULAR STUDY----------------------------
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| 168 | PREMEDICATION:
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| 169 | RECORDING SITE SITE:
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| 170 | VENTRICULAR THRESHOLD (mA):
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| 171 | REPETITIVE RESPONSES
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| 172 | VENT. EFF. REFR. PERIOD
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| 173 | BURST PACING (# REP. RESPONSES):
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| 174 | SHORTEST BURST CL:
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| 175 | INITIATION SEQUENCE OF V-T:
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| 176 | DURATION OF V-T/V-F:
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| 177 | V-T CYCLE LENGTH:
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| 178 | AXIS:
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| 179 | TERMINATION OF VT:
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| 180 | PACE OUT CYCLE LENGTH OF V-T:
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| 181 | CARDIOVERSION (J):
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| 182 | RHYTHM:
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| 183 | MEDICATIONS ON DISCHARGE:
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| 184 | CATHETERIZATION REPORT
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| 185 | ECHO REPORT
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| 186 | ECG REPORT
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| 187 | EP REPORT
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| 188 | HOLTER REPORT
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| 189 | RHEUMATOLOGY REPORT
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| 190 | ETT REPORT
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| 191 | Enter patient name or the date & time:
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| 192 | Pg.
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| 193 | CONFIDENTIAL
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| 194 | PROCEDURE DATE/TIME:
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| 195 | Select Patient Name or Date of Procedure to Delete:
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| 196 | ARE YOU SURE YOU WANT TO DELETE
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| 197 | Procedure Deleted
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| 198 | A-LEAD REPORT
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| 199 | V-LEAD REPORT
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| 200 | GENERATOR IMPLANT REPORT
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| 201 | PACEMAKER SURVEILLANCE REPORT
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| 202 | COMBINED IMPLANT/LEADS PROCEDURES
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| 203 | Enter Patient name or Date of Generator Implant:
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| 204 | Generator Information....
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| 205 | Atrial Lead Data....
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| 206 | Ventricular Lead Data...
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| 207 | GENERATOR DATA...
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| 208 | Ventricular
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| 209 | Atrial
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| 210 | Lead data entered for this patient
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| 211 | Lead implanted on
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| 212 | DEMOGRAPHIC INFORMATION
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| 213 | ACTIVE PATIENT LIST
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| 214 | This report has been set up to print with a line length of 132
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| 215 | characters. Select a device that uses a 132 character line length.
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| 216 | <RETURN> to continue
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| 217 | PACEMAKER ACTIVE PATIENT LIST
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| 218 | <RETURN> to Continue
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| 219 | EAST PSC FOLLOW-UP
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| 220 | REGISTRY ONLY
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| 221 | WEST PSC FOLLOW-UP
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| 222 | Pg.
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| 223 | GENERATOR IMPLANT DATA
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| 224 | V AND A LEAD IMPLANT DATA
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| 225 | MFR MODEL
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| 226 | SER. NO.
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| 227 | Enter Patient Name, or Date and Time:
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| 228 | SURVEILLANCE PROCEDURES
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| 229 | *** SCREEN EDIT ***
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| 230 | *** BRIEF EDIT ***
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| 231 | MCAR(698
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| 232 | TYPE OF LEAD NOT DEFINED FOR THIS PATIENT IN GENERATOR FILE
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| 233 | PRESS RETURN TO CONTINUE:
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| 234 | PACEMAKER SURVEILLANCE
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| 235 | PATIENT HAS NO CURRENT GENERATOR IMPLANT LISTED IN GENERATOR FILE
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| 236 | Entry Deleted
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| 237 | FORM TRANSFER TO NATIONAL CENTER
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| 238 | Select Reason for Transmission of this Report:
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| 239 | Transfer Report to :
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| 240 | WESTERN PACEMAKER CENTER
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| 241 | EASTERN PACEMAKER CENTER
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| 242 | Answer with 'E' for Eastern Center,'W' for Western Center, or 'B' for Both
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| 243 | BOTH EASTERN AND WESTERN PACEMAKER CENTERS
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| 244 | TRANSMIT REPORT
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| 245 | MCR(
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| 246 | PACEMAKER REPORT TRANSMISSION
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| 247 | PACEMAKER CENTER REPORT
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| 248 | REGISTRATION FORM DATA
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| 249 | REASON(S) FOR REPORT:
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| 250 | TELEPHONE FOLLOW-UP PROVIDED BY:
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| 251 | EASTERN PACEMAKER SURVEILLANCE CENTER
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| 252 | WESTERN PACEMAKER SURVEILLANCE CENTER
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| 253 | LOCAL VAMC
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| 254 | PULSE GENERATOR
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| 255 | MFR:
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| 256 | BEGINNING OF LIFE MAGNET RATE:
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| 257 | END OF LIFE MAGNET RATE:
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| 258 | TELEPHONES:
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| 259 | IMPLANTING HOSPITAL:
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| 260 | HOME:
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| 261 | WORK:
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| 262 | DATE OF INITIAL IMPLANT:
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| 263 | RESPONSIBLE PHYSICIAN:
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| 264 | MCPHYS(
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| 265 | PULSE GENERATORS INCLUDING PRESENT:
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| 266 | ATRIAL LEAD
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| 267 | VENTRICULAR LEAD
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| 268 | ATRIAL LEAD
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| 269 | MODEL #:
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| 270 | SERIAL #:
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| 271 | DATE:
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| 272 | PART 2
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| 273 | ALTERNATE CONTACT
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| 274 | ALTERNATE CONTACT ADDRESS
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| 275 | TELEPHONE TRANSMITTER:
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| 276 | MODEL #:
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| 277 | IMPLANT PARAMETERS: ATRIAL LEAD
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| 278 | THRESHOLD IN VOLTS
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| 279 | THRESHOLD IN MAs
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| 280 | AT .5 MS PW
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| 281 | RESISTANCE AT 5 VOLTS
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| 282 | R-WAVE OR P-WAVE
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| 283 | PSA USED:
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| 284 | SURVEILLANCE DATA
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| 285 | PROGRAMMED SETTINGS
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| 286 | PULSE WIDTH
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| 287 | AMPLITUDE
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| 288 | SENSITIVITY
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| 289 | REFRACTORY PERIOD
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| 290 | LOWER RATE LIMIT:
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| 291 | UPPER RATE LIMIT:
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| 292 | PACING MODE:
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| 293 | CLINIC MEASUREMENTS
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| 294 | PULSE WIDTH
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| 295 | AMPLITUDE
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| 296 | RATIO (T/L)
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| 297 | THRESHOLD WIDTH
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| 298 | THRESHOLD AMPLITUDE
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| 299 | CAPTURE
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| 300 | SENSE
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| 301 | RATE NO MAGNET:
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| 302 | RATE MAGNET:
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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