Clinical Summary Note. Digital photographs. Echo Cardiogram. Mammogram. Angiogram. BMD scan Pet scan. Xray US

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1 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 Allergy Allergy Audiology Otorhinolaryngology Breast Clinic BRCA Mutation Family History Ca Breast Genetic Susceptibility to Ca Breast High Risk Ca Breast Counseling Other Breast Clinic Risk Assessment Ca Breast Cardiology Amyloid Cardio Oncology Heart Failure Heart Rhythm Ischemic Heart Disease Marfan Thoracic Aorta Other Cardiology Structural Heart Disease (Valve, Congenital, HCM, Pericardial) Uneplained Dyspnea CGIM Complimentary General Internal Medicine Dental Specialties Dental Specialties Dermatology Acne Blistering Disease Connective Tissue Disease Dermatology - Inpatient Diffuse Rash Diffuse Skin Condition Genetics - Dermatology Page 1 of 9

2 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 Limited Rash Limited Skin Condition Lymphoma of Skin Melanoma Oral Disease Other Dermatology Pediatric Dermatology Skin Cancer or History of Skin Cancer Skin Growths or Keratosis Vasculitis Warts Endocrinology Endocrinology GI & Hepatology Esophageal Disorders:24 PH Study; Esophageal Manometry GI Neoplasia HB Neoplasia Hepatology Inflammatory Bowel Disease Jaundice Malabsorption and Failure to Thrive Motility Disorders: Anorectal Manometry, Pelvic Floor Testing, Transit Studies Other GI Other Hepatology Pancreatic Disorders Gynecology/Obstetrics Amenorrhea 3 Colposcopy/ Dysplasia 3 Comple Contraceptive Management 3 Page 2 of 9

3 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 Cysts on Ovaries 3 GYN Surgical Oncology High Risk OB 12 3 Irregular Periods 3 Other Obstetrics 12 3 Other Gynecology 12 3 Pediatric/ Adolescent Gynecology 12 3 Polycystic Ovary Syndrome 3 Reproductive Endocrinology & Fertility 12 3 Urogynecology Vulvar Disease 3 Hematology Acute Leukemia Bone Marrow Transplantation Chronic Lymphocytic Leukemia Coagulation/ Thrombophilia Lymphoma Myelodysplastic Syndrome Myeloma, Plasma Cell Disorders and Amyloidosis Myeloproliferative Disorder Non-Malignant Hematology (anemia, iron deficiency, neutropenia, thrombocytopenia, others) Other Hematology Pediatric Blood Dyscrasias Pediatric Ecessive Bleeding Pediatric Hemophilia Infectious Disease Hematology & Oncology Infectious Disease Orthopedic Infectious Disease Other Infectious Disease Transplant Infectious Disease Travel & Tropical Infectious Disease Medical Genetics Medical Genetics Page 3 of 9

4 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 Medical Oncology Brain Cancer Breast Cancer Childhood Cancer 3 Endocrine Cancer GI Cancer GU Cancer GYN Medical Oncology Head/Neck Cancer Lung Cancer Melanoma Other Oncology Sarcoma Unknown Primary Cancer Nephrology and Hypertension Nephrology and Hypertension Neurology Autoimmune Autonomic 3 Behavioral - Cognitive/Dementia Cerebrovascular Delayed Development Milestones Epilepsy/Seizure Headache Multiple Sclerosis Neuro Oncology Neuromuscular 3 6 Other Neurology Pediatric Abnormal or Pediatric Involuntary Movements Pediatric Spells Ophthalmology Cornea Page 4 of 9

5 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 COS Glaucoma NeuroOph Oculoplastics Pediatric (including Peds Neuro) Retina Uveitis Orthopedic Surgery Foot/Ankle Surgery Hand Surgery Orthopedic Oncology Orthopedic Spine surgery Orthopedic Trauma Other Orthopedic Surgery Pediatric Ortho Surgery Reconstructive Surgery Otorhinolaryngology Otorhinolaryngology Pain Medicine Advanced Neuromodualtion (Spinal Cord Stimulation, Peripheral Nerve Stimulation- Occipital, Intrathecal Drug Delivery) Cancer Pain Comple Regional Pain Syndrome (Refle Sympathetic Dystrophy, Causalgia) Failed back Surgery Syndrome Other Pain Medicine Postherpetic Neuralgia Radiculopathy (Cervical, Thoracic, Lumbar) Spine (Cervical, Thoracic, Lumbar) Pediatrics Pediatric/Adolescent Gynecology Pediatric Involuntary Movements Pediatric Spells Page 5 of 9

6 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 Pediatric Abnormal CXR or Pediatric Asthma Management Pediatric Chronic Cough Pediatric Dyspnea/Shortness of Breath Pediatric Recurrent Pneumonia Pediatric Cancers Pediatric Blood Dyscarsias Pediatric Ecessive Bleeding Pediatric Hemophilia Pediatric Dermatology Pediatric Orthopedic Surgery Pediatric Orthopedic Pediatric: Mayo Clinic Child Abuse Program Pediatric (including Peds Neuro) Physical Medicine & Rehabilitation Physical Medicine and Rehabilitation Psychiatry & Psychology Alcohol Abuse and Addiction (waiting for guidelines) Depression (waiting for guidelines) Other Psychiatry & Psychology (waiting for guidelines) Pain (waiting for guidelines) Pulmonary Abnormal CXR or Asthma Management 24 3 Chronic Cough 24 3 COPD Management 24 3 Interstitial Lung Disease 24 3 Lung Nodule/Mass Mycobacterial Disease 24 3 Other Pulmonology 24 3 Pediatric Abnormal CXR or X Pediatric Asthma Management X Pediatric Chronic Cough X Page 6 of 9

7 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 Pediatric Dyspnea/Shortness of Breath X Pediatric Recurrent Pneumonia X Pleural 24 3 Pulmonary Vasculitis 24 3 Radiation Oncology Breast Cancer 3 CNS 3 GI Cancer 3 GU Cancer 3 GYN Cancer 3 Head & Neck Cancer 3 Lung/Thoracic Cancer 3 Lymphoma/ Leukemia 3 Other Radiation Oncology 3 Pediatric Cancers 3 Sarcoma 3 Radiology Radiology Rheumatology Rheumatology Sleep Disorders Sleep Disorders Spine Center Spine Center Sports Medicine Sports Medicine Surgery- Cardiovascular Surgery Surgery- Colon & Rectal Surgery Cardiovascular Surgery Colon & Rectal Surgery Surgery- General Surgery General Surgery Page 7 of 9

8 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/2016 Surgery- Neurosurgery Neurosurgery Surgery- Oral & Maillofacial Surgery Oral & Maillofacial Surgery Surgery- Plastic Surgery Plastic Surgery Surgery- Thoracic Surgery Thoracic Surgery Surgery- Vascular Surgery Vascular Surgery Transplant Center Transplant Center Urology Urology Vascular Center Aneurysm Other Vascular Peripheral Artery Disease Vascular Wound Care Venous Insufficiency Venous Thrombosis Women's Health Clinic Menopause Management (Hormonal and Non- Hormonal options) Other WHC Guideline to use when specific guidelines have not been identified: Timeline Key Requirement Key Images: Provide most current image for each modality relevant to the = Relevant to request, no time guidelines * Required if applicable to the specific question request within the past 12 months or pertinent. 3 = Most recent completed in past 3 months, or pertinent Required for all cases. Labs & Reports: Provide labs & reports relevant to the request within the 6 = Most recent completed in past 6 months, or pertinent past 12 months or pertinent (10 pages or less). 12 = Most recent completed in past 12 months, or pertinent 24 = Most recent completed in past 24 months, or pertinent Page 8 of 9

9 Ankle brachial inde Radiation Records (H) Eternal econsult Guidelines Updated 12/9/ = All completed in past 3 months, or pertinent 6 = All completed in past 6 months, or pertinent 12 = All completed in past 12 months, or pertinent 24 = All completed in past 24 months, or pertinent Page 9 of 9