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Name: Date:
COMMENTS:
RIGHT
CCA
ECA
ICA
VERTEBRAL
LEFT
CCA
ECA
ICA
VERTEBRAL
REMARKS
Original Signed
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
IMPRESSION:
Original Signed
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
Remarks
Original Signed
Carolcel Jean A. Bardaluza, RN
Vascular Technologist Leanne Therese L. Zuniega, MD
MCI DOC 85 2020 Consultant