HTMLFORM

<htmlform >

	<!-- Autogenerated example form  (template from 01-Nov-2010 -->
	<macros>
		paperFormId = (Fill this in)
		headerColor =#009d8e
		fontOnHeaderColor = white
	</macros>

	<style>
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<style>
table, tr, td
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border:1px solid black;
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padding: 0.1cm;
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</style>

	<span style="float:right">Paper Form ID: $paperFormId</span>
	<h2>Cardiac MRI Adenosine Stress Protocol</h2>

	<section headerLabel="1. Encounter Details">
		<table class="baseline-aligned">
			<tr>
				<td>Date:</td>
				<td><encounterDate default="today"/></td>
			</tr>
			<tr>
				<td>Location:</td>
				<td><encounterLocation/></td>
			</tr>
			<tr>
				<td>Provider:</td>
				<td><encounterProvider/></td>
			</tr>
		</table>
	</section>

<section data-section-name="Procedure">
<header class="level1">Cardiac MRI: Adenosine Stress Protocol</header>

<p>
<label for="label_text" id="label_text">Field strength:</label>
<obs conceptId="164107" type="number" id="field_strength_input" name="Field strength" data-field-units="T" min="" max="" value="1.5"/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 540px;">T</label>
</p>



<p>
<label for="label_text">Adenosine stress protocol:</label>
<obs conceptId="164108" style="textarea" defaultValue="0.14 mg/kg/min adenosine infused over 4 minutes with stress perfusion imaging performed during the last minute of the adenosine infusion using an FGRE-ET sequence and a gadolinium dose of 0.1 mmol/kg. Rest perfusion imaging was performed was then performed after appropriate delay using additional gadolinium dose of 0.1 mmol/kg. Cine white blood imaging including short axis and two, three and four chamber long axis views was performed using a FIESTA sequence to evaluate cardiac morphology and function. Delayed enhanced imaging was performed using an Inversion recovery prepared gradient echo sequence. Images were postprocessed on a computer workstation to assess cardiac anatomy and ventricular function."  />
</p>
</section>

<section data-section-name="Clinical information">
<header class="level1">Clinical information</header>
<p>
<obs conceptId="164109" style="textarea" name="Clinical information"/>
</p>
</section>

<section data-section-name="Comparison">
<header class="level1">Comparison</header>
<p>
<obs conceptId="164110" style="textarea" defaultValue="None"/>
</p>
</section>




<section data-section-name="Findings">
<header class="level1">Findings</header>
<p>
<label for="label_text">Stress perfusion imaging:</label>
<obs conceptId="164111" name="Stress perfusion imaging" defaultValue="Normal"/>
</p>

<p>
<label for="label_text">Rest perfusion imaging:</label>
<obs conceptId="164112" name="Rest perfusion imaging" defaultValue="Normal"/>
</p>

<p>
<label for="label_text">Cine images:</label>
<obs conceptId="164113" style="textarea" defaultValue="Normal cardiac anatomy and normal cardiac chamber size. Normal left ventricular wall motion and function. "/>
</p>

<section data-section-name="Left ventricle">
<header class="level2">Left ventricle</header>
<p>
<label for="label_text" id="label_text">End-diastole volume:</label>
<obs conceptId="164114" name="End-diastole volume" data-field-units="mL" min="0" max=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 500px;">mL</label>
</p>

<p>
<label for="label_text" id="label_text">End-systolic volume:</label>
<obs conceptId="164115" name="End-systolic volume" data-field-units="mL" min="0" max=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 500px;">mL</label>
</p>
<p>
<label for="label_text" id="label_text">Stroke volume:</label>
<obs conceptId="164116" name="Stroke volume" data-field-units="mL" min="0" max=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 530px;">mL</label>
</p>
<p>
<label for="label_text" id="label_text">Ejection fraction:</label>
<obs conceptId="164117" name="Ejection fraction" value="" data-field-units="%"/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 530px;">%</label>
</p>
<p>
<label for="label_text" id="label_text">Mass:</label>
<obs conceptId="164118" name="Mass" data-field-units="g" min="0" max=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 590px;">g</label>
</p>
<p>
<label for="label_text" id="label_text">Antero-septal wall (end-diastole):</label>
<obs conceptId="164119" name="Antero-septal wall" data-field-units="cm" min="0" max=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 435px;">cm</label>
</p>
<p>
<label for="label_text" id="label_text">Infero-lateral wall (end-diastole):</label>
<obs conceptId="164120" name="Infero-lateral wall" data-field-units="cm" min="0" max=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 435px;">cm</label>
</p>
<p>
<label for="label_text" id="label_text">Left ventricular diameter measured at the base (end-diastole):</label>
<obs conceptId="164121" name="Left ventricular diameter end-diastole" value=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 280px;">cm</label>
</p>
<p>
<label for="label_text" id="label_text">Left ventricular diameter measured at the base (end-systole):</label>
<obs conceptId="164122" name="Left ventricular diameter end-systole" value=""/>
<label for="label_placeholder" id="label_placeholder" style="padding-right: 280px;">cm</label>
</p>
<p>
<label for="label_text" id="label_text">Delayed enhancement:</label>
<obs conceptId="164123" name="Delayed enhancement" defaultValue="There is no delayed enhancement of the myocardium or pericardium"/>
</p>


</section>
<section data-section-name="Reference">
<header class="level2">Reference</header>
<p>
Reference values from: Maceira et al., Normalized left ventricular systolic and diastolic function by steady state free precession cardiovascular magnetic resonance. J Cardiovascular Magn Reson 2006; 8:417-426.
</p>
</section>

</section>

<section data-section-name="Impression">
<header class="level1">Impression</header>
<p>
<obs conceptId="
164124
" name="Impression" style="textarea"/>
</p>
</section>

	<submit/>




</htmlform>