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/clinical/cckm-tools/content/order-sets/ambulatory/transplant/name-113261-en.cckm

20170247

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UWHC,UWMF,

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Transplant

OP - Lung Transplant Evaluation - Procedures, Imaging, Consults [3741]

OP - Lung Transplant Evaluation - Procedures, Imaging, Consults [3741] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Transplant


LUNG TRANSPLANT EVAL - PROCEDURES, IMAGING, CONSULTS - OP [3741]
Imaging Orders
Imaging [106480]
CT Sinus without IV Contrast [R70486B] Status: Future, Expires: 8/10/17, Normal, Routine, Pre-
transplant recipient. ABN not required.
Bone Mineral Density Axial (w Appendicular & Vertebral
Fracture Assessment (VFA) (PRN) (BMD) [R07029]
Status: Future, Expires: 12/7/16, Normal, Routine, Pre-
transplant recipient. ABN not required.
CT Chest w/o IV Contrast [R71250] Status: Future, Expires: 8/10/17, Normal, Routine, Pre-
transplant recipient. ABN not required. Please measure right
lung, left lung, and costal to costal diameter.
Transthoracic Resting Echocardiogram [ECH0003] Status: Future, Expires: 7/10/17, Normal, Routine, Pre-
transplant recipient. ABN not required.
NM Lung Perfusion - Quantitative [R78597] Status: Future, Expires: 8/10/17, Normal, Routine, Pre-
transplant recipient. ABN not required. Lung transplant
evaluation.
X-ray Panorex (Orthopantogram) [R70355] Status: Future, Expires: 8/10/17, Normal, Routine, Pre-
transplant recipient. ABN not required.
Procedures
Procedures/Requests for Procedures [106483]
If the patient has not been seen in pulmonary clinic for an initial visit but will be during this evaluation, please select the
following PFTs: spirometry with and without bronchodilator, lung volumes, diffusing capacity, arterial blood gas on room
air.
Spirometry, ABG on Room Air [999992] Routine
Reason for Exam: Lung transplant evaluation
Specify Test: Spirometry,ABG on Room Air (Pulmonary Lab
to draw)
Pre-transplant recipient. ABN not required.
Spirometry - Before & After Bronchodilator, Lung
Volumes, Diffusing Capacity, ABG on O2 [999992]
Routine
Reason for Exam: Lung transplant evaluation
Specify Test: Spirometry - Before & After Bronchodilator,Lung
Volumes,Diffusing Capacity,ABG on Oxygen (Please indicate
FIO2 desired in comments)
Pre-transplant recipient. ABN not required.
ECG - 12 Lead [EKG0008] Status: Future, Expires: 7/10/17, Normal, Routine, Pre-
transplant recipient. ABN not required.
Request for RT Procedure - Oximetry 6 (six) Minute
Walk [1009329]
What procedure would you like the specialist to perform?
(This does not include a consult or transfer of care.): RT -
Oximetry 6 (six) Minute Walk
Request for Cardiology Procedure -Cardiac Cath
[1009283]
What procedure would you like the specialist to perform?
(This does not include a consult or transfer of care.): Cardiac
Cath
Esophageal Manometry [GI0031] Status: Future, Expires: 6/10/17, Normal, Routine, Qty-1
Impedence pH [GI0027] Status: Future, Expires: 6/10/17, Normal, Routine, Qty-1
Consult/Transfer of Care
Consult [106484]
Consult to Infectious Diseases - INSIDE UW Health
[1009045]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Infectious Diseases - OUTSIDE UW Health
[1009045]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
Page 1 of 5
Printed by LIND, JANNA S [JSL237] at 6/10/2016 11:38:39 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Consult to Cardiothoracic Surgery - INSIDE UW Health
[1009343]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Cardiothoracic Surgery - OUTSIDE UW
Health [1009343]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Consult to Cardiovascular Surgery - INSIDE UW Health
[1009145]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Cardiovascular Surgery - OUTSIDE UW
Health [1009145]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Consult to Social Work - INSIDE UW Health [1009273] What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Social Work - OUTSIDE UW Health
[1009273]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Pulmonary Rehab - INSIDE UW Health
[1009451]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Pulmonary Rehab - OUTSIDE UW Health
[1009451]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
Page 2 of 5
Printed by LIND, JANNA S [JSL237] at 6/10/2016 11:38:39 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

contraindications to lung transplant?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Consult to Health Psychology (outpt) - INSIDE UW
Health [9138]
Request Type: Consultation(opinion/advise) plus procedure if
needed
Reason for this request: Are there any contraindications to
lung transplant?
Consult to Health Psychology (outpt) - OUTSIDE UW
Health [9138]
Request Type: Consultation(opinion/advise) plus procedure if
needed
Reason for this request: Are there any contraindications to
lung transplant?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Consult to Nutrition - INSIDE UW Health [1009069] What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Nutrition - OUTSIDE UW Health [1009069] What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Consult to Dental Services - INSIDE UW Health
[1009271]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Dental Services - OUTSIDE UW Health
[1009271]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Page 3 of 5
Printed by LIND, JANNA S [JSL237] at 6/10/2016 11:38:39 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Consult to Otolaryngology - INSIDE UW Health
[1009027]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Consult to Otolaryngology - OUTSIDE UW Health
[1009027]
What question regarding the patient's medical care would you
like the specialist to answer? (REQUIRED): Are there any
contraindications to lung transplant?
Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even
when wearing glasses?
Because of a physical, mental, or emotional condition, do you
have serious difficulty concentrating, remembering, or making
decisions? (5 yrs old or older):
Do you have serious difficulty walking or climbing stairs? (5
yrs old or older):
Because of a physical, mental, or emotional condition, do you
have difficulty doing errands alone such as visiting a doctor's
office or shopping? (15 yrs old or older):
Do you have difficulty dressing or bathing? (5 yrs old or
older):
Diagnosis
Diagnosis [106485]
Alpha-1-antitrypsin deficiency [273.4.ICD-9-CM] Alpha-1-antitrypsin deficiency
Bronchiectasis without acute exacerbation [494.0.ICD-
9-CM]
Bronchiectasis without acute exacerbation
Bronchiolitis obliterans [145682] Other chronic bronchitis
Chronic airway obstruction [179806] Chronic airway obstruction, not elsewhere classified
Cystic fibrosis with pulmonary manifestations
[277.02.ICD-9-CM]
Cystic fibrosis with pulmonary manifestations
Emphysema, other [492.8.ICD-9-CM] Other emphysema
Encounter for long-term (current) use of medications
[195074]
Encounter for long-term (current) use of other medications
Hermansky-Pudlak syndrome [127273] Other disturbances of aromatic amino-acid metabolism
Hypersensitivity pneumonitis [143988] Unspecified allergic alveolitis and pneumonitis
Idiopathic pulmonary fibrosis, unspecified [515.ICD-9-
CM]
Postinflammatory pulmonary fibrosis
Idiopathic fibrosing alveolitis [446917] Idiopathic interstitial pneumonia, not otherwise specified
Interstitial Lung Disease, unspecified [515.ICD-9-CM] Postinflammatory pulmonary fibrosis
Lung involvement associated with another disorder
[311661]
Lung involvement in other diseases classified elsewhere
Lung involvement in systemic sclerosis [991596] Diagnosis
Lymphangioleiomyomatosis [992073] Diagnosis
Organ transplant candidate [310964] Awaiting organ transplant status
Primary Ciliary Dyskinesia-Kartagener's Disease (Situs
inversus) [759.3.ICD-9-CM]
Situs inversus
Chronic pulmonary heart disease [911906] Diagnosis
Page 4 of 5
Printed by LIND, JANNA S [JSL237] at 6/10/2016 11:38:39 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org

Pulmonary hypertension, primary [330213] Primary pulmonary hypertension
Sarcoidosis [135.ICD-9-CM] Sarcoidosis
Systemic sclerosis [710.1.ICD-9-CM] Systemic sclerosis
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
END OF SMARTSET [4852]
Other Chief Complaint
Page 5 of 5
Printed by LIND, JANNA S [JSL237] at 6/10/2016 11:38:39 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2016CCKM@uwhealth.org