Venous Duplex Imaging Worksheet Lower Extremity Acute by bti81428

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									                           Ankle – Brachial Index (ABI) Worksheet
Name:                                                                    Date:    /   /02
Sex:          Male     Female                     DOB:    /   /          Hospital No.:
Referring Physician:                                                     Sonographer’s Name:
Indication:


Presentation:
          Asymptomatic:
          Symptomatic:          Right     Left       Bilateral
          Claudication:          No     Yes       Describe:
          Rest pain:             No     Yes       Describe:
          Ulcers/gangrene:       No     Yes       Describe:
          Other:                 No     Yes       Describe:
          Pulses:      Normal     Abnormal Describe:


Risk Factors:                    No Yes
Hypertension
Diabetes mellitus
Elevated cholesterol
Smoking
Carotid disease
Cardiac disease
Family history
Previous vascular intervention




Ankle-Brachial Pressures
                                Right                         Left
Arm (brachial)                          mmHg                         mmHg (use higher arm pressure to calculate ABI)
Ankle:
   Dorsalis pedis                       mmHg                         mmHg
                                          Index                      Index
   Posterior tibial                     mmHg                         mmHg
                                        Index                        Index


Reason for limited examination:


Compared to previous examination:


Physician:

								
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