Вы находитесь на странице: 1из 4

MEDICAL CENTER IMUS

Diversion Road, Palico IV, Imus, Cavite


(046)472-2220; 472-3987 to 89; (02) 809-1646

DUPLEX ULTRASOUND REPORT

Name: Date:

VELOCITIES (M/SEC) RIGHT LEFT


PSV EDV PSV EDV
CCA
ICA
ECA
IC/CC
Vertebral O
Vert 1
Vert 2

COMMENTS:
RIGHT
CCA

ECA

ICA

VERTEBRAL

LEFT
CCA

ECA

ICA

VERTEBRAL

REMARKS

Original Signed

Leanne Therese L.Zuniega, MD


MCI DOC 82 2020 CONSULTANT
MEDICAL CENTER IMUS
Diversion Road, Palico IV, Imus, Cavite
(046)472-2220; 472-3987 to 89; (02) 809-1646

CAROTID DUPLEX SCAN

Name: Age: Patient No.:


Address: Study No.:
Date: Referring MD:

VASCULAR HISTORY
SMOKER/NON OBESE HYPERTENSION
PREVIOUS DIABETES HYPERLIPIDEMIA
CURRENT P.V.D. CARDIAC
Blood Pressure RIGHT LEFT

CLINICAL PRESENTATION
CAROTID BRUIT ASYMPTOMATIC VASCULAR SURGERY
T.I.A. PRIND/RIND STROKE
DYSPHASIA HEMIPLEGIA AMAUROSIS FUGAX
VERTIGO HEADACHE SYNCOPE
GLAUCOMA EYE OPERATION EYE INJURY

OTHER

PLAQUE MORPHOLOGY

TYPE I UNIFORMLY ECHOLUCENT WITH THIN ECHOGENIC CAP (HOMOGENEOUS HYPOCHOIC)


* HIGH RISK FOR PLAQUE RUPTURE AND EMBOLISM REGARDLESS OF % STENOSIS

TYPE II SUBSTANTIALLY ECHOLUCENT WITH SMALL AREAS ( < 50% ) OF ECHOGENICITY


(HETEROGENEOUS HYPOECHOIC)
TYPE III DOMINANTLY ECHOGENIC W/ SMALL AREAS ( < 50% ) OF ECHOLUCENCY
(HETEROGENEOUS HYPERECHOIC)
TYPE IV UNIFORMLY ECHOGENIC (HOMOGENEOUS HYPERECHOIC)
TYPE V CALCIFIED

IMPRESSION:

Original Signed

Leanne Therese L. Zuniega, MD


MCI DOC 83 2020 CONSULTANT
MEDICAL CENTER IMUS Name:
Diversion Road, Palico IV, Imus, Cavite Age/Sex: Date:
(046)472-2220; 472-3987 to 89; (02) 809-1646 Address:

Tel No.: Room No.:


ARTERIAL DUPLEX STUDY Requesting Physician:
LOWER EXTREMITY
Hosp. No.: Study No.:

Reason for referral:


History:
Physical Examination:

RIGHT LEG
Spectral Display
B-mode Color Flow PSV EDV Waveform
DEIA
CFA
DFA
SFA P
SFA M
SFA D
POP A
TPT
PTA D
ATA
DPA
Peroneal
LEFT LEG
Spectral Display
B-mode Color Flow PSV EDV Waveform
DEIA
CFA
DFA
SFA P
SFA M
SFA D
POP A
TPT
PTA D
ATA
DPA
Peroneal

REMARKS:

INTERPRETATION:

Original Signed

Carolcel Jean B. Nicanor, RN Leanne Therese L. Zuniega, MD


Technologist Consultant
MCI DOC 84 2020
MEDICAL CENTER IMUS Name:
Diversion Road, Palico IV, Imus, Cavite Age/Sex: Date:
(046)472-2220; 472-3987 to 89; (02) 809-1646
Tel No.: Room No.:
DVT SCREENING Requesting Physician:
LOWER EXTREMITY
Hosp. No.: Study No.:

Reason for referral:


History:
RIGHT LEG
B-mode Image Color Flow
DEIV
CFV
GSV
DFV
SFV P
SFV M
SFV D
SFV D POST
POP
POP D
SPJ
SSV
PTV D
Peroneal
LEFT LEG
B-mode Image Color Flow
DEIV
CFV
GSV
DFV
SFV P
SFV M
SFV D
SFV D POST
POP
POP D
SPJ
SSV
PTV D
Peroneal

Remarks

Original Signed
Carolcel Jean A. Bardaluza, RN
Vascular Technologist Leanne Therese L. Zuniega, MD
MCI DOC 85 2020 Consultant