|
UNILATERAL OR LIMITED BILATERAL?
|
|
|
UNILATERAL
|
LIMITED BILATERAL
|
|
U/S TECH
|
|
|
Stella Bitzaya
|
Sabrina Durazo, RVS
|
|
FU or Separate scan?
|
|
|
FU Scan
|
Separate scan
|
|
FU for which leg?
|
|
|
FU Left Leg
|
FU Right Leg
|
|
Procedure FU
• • •
|
Procedure FU
• • •
|
|
FU LT NEGATIVE SCAN
|
FU RT NEGATIVE SCAN
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
|
FU LT POSITIVE SCAN
|
FU RT POSITIVE SCAN
|
|
FU LT POSITIVE DVT
|
FU RT POSITIVE DVT
|
|
FU NEGATIVE DVT
|
FU NEGATIVE DVT
|
|
FU LT POSITIVE SVT
|
FU RT POSITIVE SVT
|
|
FU NEGATIVE SVT
|
FU NEGATIVE SVT
|
|
FU LT POSITIVE EHIT
|
FU RT POSITIVE EHIT
|
|
FU NEGATIVE EHIT
|
FU NEGATIVE EHIT
|
|
Where is FU DVT located?
• • •
|
Where is DVT located?
• • •
|
|
Compressibility
• • •
|
Compressibility
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
|
Where is SVT located?
• • •
|
Where is SVT located?
• • •
|
|
Compressibility
• • •
|
Compressibility
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
|
Where is EHIT located?
• • •
|
Where is EHIT located?
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
|
Which leg?
|
|
|
Left Leg
|
Right Leg
|
|
LT NEGATIVE SCAN
|
RT NEGATIVE SCAN
|
|
Nima Sign off
|
Nima Sign off
|
|
LT POSITIVE SCAN
|
RT POSITIVE SCAN
|
|
LT POSITIVE DVT
|
RT POSITIVE DVT
|
|
NEGATIVE DVT
|
NEGATIVE DVT
|
|
LT POSITIVE SVT ONLY (no secondary findings)
|
RT POSITIVE SVT ONLY (no secondary findings)
|
|
NEGATIVE SVT
|
NEGATIVE SVT
|
|
LT POSITIVE EHIT ONLY (no secondary findings)
|
RT POSITIVE EHIT ONLY (no secondary findings)
|
|
NEGATIVE EHIT
|
NEGATIVE EHIT
|
|
Only LT DVT finding
|
Only RT DVT finding
|
|
LT DVT and secondary finding (SVT or EHIT)
|
RT DVT and secondary finding (SVT or EHIT)
|
|
Secondary LT SVT (DVT finding)
|
Secondary RT SVT (DVT finding)
|
|
Secondary LT EHIT (DVT finding)
|
Secondary RT EHIT (DVT finding)
|
|
Where is DVT located? (only DVT)
• • •
|
Where is DVT located? (only DVT)
• • •
|
|
Compressibility
• • •
|
Compressibility
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
|
Where is DVT located?
• • •
|
Where is DVT located?
• • •
|
|
Compressibility
• • •
|
Compressibility
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Where is SVT located? (Secondary)
• • •
|
Where is SVT located? (Secondary)
• • •
|
|
Compressibility
• • •
|
Compressibility
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Where is EHIT located? (Secondary)(input grade before location)
• • •
|
Where is EHIT located? (Secondary)(input grade before location)
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
|
Where is SVT located?
• • •
|
Where is SVT located?
• • •
|
|
Compressibility
• • •
|
Compressibility
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
|
Where is EHIT located? (input grade before location)
• • •
|
Where is EHIT located? (input grade before location)
• • •
|
|
Size (strictly mm only number, any other info in specific comments)
|
Size (strictly mm only number, any other info in specific comments)
|
|
Specific comments
|
Specific comments
|
|
Nima Sign off
|
Nima Sign off
|
