REPORTING FORMAT
THE FOLLOWING FORMAT IS GIVEN TO ALL STUDENTS ANDTRAINEES
TO HELP THEM IN PREPARING A DIAGNOSTIC REPORT:
OBSTETRICS
PREGNANT _________ FETAL ________
INTRAUTERINE _________ MEASURMENT ________
NO OF FOETII _________ ________
FETAL HEART BEAT _________ ________
FETAL MOVEMENT _________ FOLLOWING
PRESENTATION &LIE _________ FETAL STRUCTURE
PLACENTAL SEEN NORMAL _________
LOCALIZATION _________ _________
PLACENTAL _________
GRADING _________ _________
RETROPLACENTAL FETAL
CLOTS _________ ABNORMALITY _________
INTERNAL OS _________ GESTATIONAL AGE _________
(According to LMP)
AMOUNT OF
AMNIOTIC FLUID _________ GESTATIONAL AGE _________
(According to previous ultrasound)
BIOPHYSICAL PROFILE _________
GESTATIONAL AGE _________
(According to present ultrasound)
COMMENTS
______________________________________________________________
GYNAECOLOGY
POSITION OF UTERUS ____________
SIZE OF UTERUS ____________
ENDOMETRIAL CAVITY ____________
FOCAL MASSES IN UTERUS ____________
OVARY (RIGHT) ____________CM
OVARY (LEFT) ____________CM
OVARIAN FOLLICLE
(RIGHT OV) ______________
OVARIAN FOLLICLE
(LEFT OV) ______________
OVARIAN MASS ______________
ADNEXAL MASS ______________
FREE FLUID IN CUL-DE-SAC ______________
COMMENTS _____________________________________
PELVIS (GYN) I
Scan of the pelvis showed anteverted anteflexed uterus.
Uterus measuring about 6.7x4.2 cms with no focal mass.
Right ovary measuring about 2.2x3.4 cms with no cyst.
Left ovary measuring about 2.3x2.3 cms with no cyst.
No adnexal mass was seen.
No free fluid seen in the cul-de-sac.
PELVIS (GYN) II
Scan of pelvis showed anteverted anteflexed uterus.
Uterus was enlarged with irregular outer contour and decreased
echogenecity resembling the picture of multiple fibroids.
Both ovaries were seen normal.
No adnexal mass was seen.
No free fluid seen in the cul-de-sac.
PELVIS (GYN) III
Longitudinal and transverse scan of the pelvis was done.
Uterus was anteverted anteflexed.
It was of normal size.
Outer surface was smooth.
The echopattern was seen normal.
Endometrial canal was thin and central.
No focal mass was seen.
IUCD was seen within the uterine cavity.
Both ovaries were of normal size with no cyst.
No free fluid seen in the cul-de-sac.
PELVIS (OBS) I
Scan of the pelvis showed single Intra uterine pregnancy, corresponding to
the gestational age of 30 weeks + - week.
Fetal cardiac activity and fetal movement seen.
Cephalic presentation at the time of scan.
Placenta is seen posterior, no previa.
Adequate amount of amniotic fluid seen.
BPD : 7.5 cms
F.L : 5.5 cms
A.C : 27 cms
Weight : 1.9 kg
Fetal stomach, urinary bladder, spine, kidneys, face profile and 4- chamber
view of hearts seen normal.
PELVIS (OBS) II
Scan of the pelvis showed single intra uterine pregnancy, corresponding to
the gestational age of 18 weeks + - week.
Foetal cardiac activity and foetal movement seen.
Placental is posterior. No previa.
Adequate amount of amniotic fluid seen.
BPD : 4.0 cms
F.L : 2.0 cms
Foetal stomach, urinary bladder, spine, kidneys, face profile and 4-chamber
view of the heart seen normal with normal rate and rhythm.
No evidence of nuchal fold thickening seen.
No uterine mass was seen.
No adnexal mass was seen.
PELVIS (OBS) III
Scan of the pelvis showed single intra uterine pregnancy.
CRL corresponds to the gestational age of 9-10 weeks.
No foetal cardiac activity seen.
Keeping in view the clinical facts, the above findings are
suggestive of missed abortion.
PELVIS (OBS) IV
Scan of the pelvis showed single gestational sac within the
uterine cavity.
Sac corresponds to the gestational age of 4 weeks + - 4 days.
Repeat scan is advised after 2 weeks to see the foetal pole and
cardiac flicker.
PELVIS (OBS) V
Scan of the pelvis showed slightly enlarged uterus.
There is an irregular gestational sac within the uterine cavity,
corresponding to 5 weeks with no Foetal pole.
Keeping in the view the clinical facts, the above findings are
suggestive of missed abortion.
However, if the patient is not sure of her dates, repeat scan
would be helpful.
PELVIS VI
Scan of the pelvis showed single gestational sac within the
uterine cavity.
Sac corresponds to the gestational age of 6 weeks + - 4 days.
Cardiac flicker was seen within the foetal pole.
Adequate amount of amniotic fluid seen.
LIVER
SIZE: Normal
Enlarged: Minimal – Moderate - massive
Shrunken: Minimal – Markedly
SURFACE: Smooth – Irregular
PARENCHYMAL
ECHOGENECITY: Normal – Increased – Decreased
Homogeneous - Heterogeneous
Suggestive of ______________________
FOCAL MASS: No____ Yes (size) ________ Site ______
Outer surface – Smooth - Irregular
Consistency: Cystic – Solid – Complex
Above mentioned focal mass resemble with _____
HEPATIC VEINS: Normal – Dilated - Obliterated
PORTAL VEINS: Normal – Dilated - Obliterated
INTRA HEPATIC
DUCTS: Normal – Dilated
FREE FLUID
AROUND LIVER : - Absent
- Present: Minimal – Moderate – Massive
- Ascetic
- Pleural effusion.
- Sub diaphragmatic collection ______
LIVER I
Scan showed normal size and shape.
Outer surface was smooth.
No focal mass was seen.
The echogenecity of the parenchymal was seen normal and homogeneous.
Minor portal veins and hepatic veins were normal.
No intra hepatic duct dilatation seen.
No free fluid or localized collection seen around the liver.
LIVER II
Scan of the liver showed slight enlargement.
No focal mass was seen.
The echogenecity of the parenchymal was seen increased resembling
Inflammatory changes.
Advised lab. Investigation / LFT
No intra hepatic duct dilatation seen.
Minor portal veins & hepatic veins were normal.
No free fluid seen around the liver.
LIVER III
Scan of the liver showed decreased in size with increased echogenecity
Resembling cirrhosis.
No focal mass was seen.
No intra hepatic duct dilatation was seen.
Minor portal veins & hepatic veins are obliterated.
No free fluid seen around the liver.
GALL BLADDER
SIZE: Normal – Distended – Contracted
STONE: No _____ Yes (Number) _____ Size _____
SLUDGE No _____ Yes _____
GROWTH: No _____ Yes (size) ________
WALL: Normal – Thickened
a) Increased echogenecity
b) Decreased echogenecity
CBD: Measures ________cm
GALL BLADDER
Scan showed normal size and shape.
There is no evidence of stones.
No mass or sludge was seen.
Wall showed no thickening.
No localized collection seen around GB.
CBD was seen within normal limits.
PANCREAS
SIZE: Normal - Enlarged
FOCAL MASS: No
Yes (size) _______ Consistency _______
ECHOGENECITY: Normal – Decreased - Increased
CALCIFICATION: No / Yes
DUCT: Normal /Dilated
PANCREAS
It was of normal size and shape.
No focal mass was seen.
No duct dilatation seen.
The echogenecity was seen normal.
No para pancreatic collection seen.
No para pancreatic lymph node enlargement seen.
SPLEEN
SIZE: ____________ cms
FOCAL MASSES: No
Yes (size) _____
ECHOPATTERN: Normal – Increased - Decreased
SPLEENIC VEIN: Normal - Dilated
FLUID AROUND
SPLEEN: No / Yes
SPLEEN
It was of normal size and shape.
The outer surface was smooth.
No focal mass was seen.
The echogenecity was seen normal.
There was no evidence of splenic vein dilatation.
No localized collection seen.
RIGHT KIDNEY
SIZE: ____________x___________cms
SURFACE: Smooth - Irregular
FOCAL MASSES: No
Yes – Cystic – solid - complex
Suggestive of _______________
CORTICAL THICKNESS: __________ cms
PARENCHYMAL: Normal – increased - Decreased
ECHOGENECITY: Suggestive of Parenchymal changes Grade___
CORTICO MEDULLARY
DISTINCTION: Intact - Obliterated
STONE: No
Yes (Number) ______ Site: ______
HYDRONEPHROSIS: No __ Yes___ ( minimal- Moderate –Massive)
PERINEPHRIC COLLECTION: No ___ Yes ___
URETER: Normal / Dilated
RIGHT KIDNEY
Right Kidney measured about ______ x ______ cms
The outer surface was smooth.
There was no focal mass seen.
Cartico medullary distinction was intact.
The echogenecity of the cortex was seen normal.
Collecting system showed no stone or hydronephrosis.
Ureter was not seen dilated.
LEFT KIDNEY
SIZE: ____________x___________cms
SURFACE: Smooth - Irregular
FOCAL MASSES: No
Yes – Cystic – solid - complex
Suggestive of _______________
CORTICAL THICKNESS: __________ cms
PARENCHYMAL: Normal – increased - Decreased
ECHOGENECITY: Suggestive of Parenchymal changes Grade___
CORTICO MEDULLARY
DISTINCTION: Intact - Obliterated
STONE: No
Yes (Number) ______ Site :______
HYDRONEPHROSIS: No __ Yes___ ( minimal- Moderate –Massive)
PERINEPHRIC COLLECTION: No ___ Yes ___
URETER: Normal / Dilated
LEFT KIDNEY
Left Kidney measured about ______ x ______ cms
The outer surface was smooth.
There was no focal mass seen.
Cartico medullary distinction was intact.
The echogenecity of the cortex was seen normal.
Collecting system showed no stone or hydronephrosis.
Ureter was not seen dilated.
URINARY BLADDER
SIZE: Normal - Distended
FOCAL MASS: No – YES
STONE: No
Yes (Number) _____
WALL THICKENING: No
Yes – Regular – Irregular
INTERNAL ECHOES: No
Yes – suggestive of _________
URINARY BLADDER
Scan showed normal size and shape.
No evidence of stone.
No mass or growth seen.
Wall showed no thickening.
Pre-void volume ______ ml
Post-void volume _____ ml
PROSTATE
SIZE: Normal - Enlarged
SHAPE: Normal - Distorted
OUTER CONTOUR: Smooth - Irregular
FOCAL MASS: Present - Absent
CALCULI: Present - Absent
BENIGN HYPERPLASIA: Present – Absent
PROSTATE
Scan of the prostate was done with adequate bladder filling.
Longitudinal and transverse scan showed smooth outer surface.
Size and shape was seen normal.
No focal mass was seen.
There is no evidence of prostatic calculi.
TESTES
SIZE: Normal – enlarged - Decreased
SURFACE: Smooth - Irregular
PARENCHYMAL
ECHOGENECITY: Normal – Increased - decreased
FOCAL MASS: Present - Absent
FLUID AROUND TESTES: Present – Increased - Decreased
EPIDIDYMUS: Normal - Enlarged
TESTES
Longitudinal and transverse scan of the scrotum was done with 7.5 MHz
probe.
Both testes were of normal size and shape with smooth outer surface.
The echogenecity of the parenchyma was seen normal.
No focal mass was seen.
Normal fluid was seen around the testes.
Epididymus was seen normal.
No cystic tubular structures seen adjacent to the testes.
THYROID
SIZE: Normal - Enlarged
OUTER CONTOUR: Smooth - Irregular
ISTHMUS: Normal - Enlarged
FOCAL MASSES: Present – Absent
THYROID
Longitudinal and transverse scan of the thyroid was done using 7.5 MHz
probe.
Both lobes were of normal size and shape with smooth outer surface.
Isthmus was seen normal.
No focal mass was seen in both the lobes.
BOTH BREASTS
GLANDULAR TISSUE: Normal - Enlarged
FIBROUS TISSUE: Normal - Increased
DUCT DILATATION: Present - Absent
FOCAL MASS: Present - Absent
VENOUS ENGORGEMENT: Present - Absent
BOTH BREASTS
Longitudinal and transverse scan of both the breasts was done using 7.5 MHz
probe.
Normal glandular tissue was seen.
Normal intervening fibrous tissue was seen.
No duct dilation was seen.
No focal mass was seen.
No veins engorgement seen.
LEGS (DOPPLER)
Color Doppler of both the limbs
FEMOROL, POPLITEAL, TIBIAL AND SUPERFICIAL VESSELS:
ARTERIAL FLOW: Normal - Obstructed
VENOUS FLOW: Normal - Obstructed
VENOUS COMPLIANCE: Compressible – Non compressible
PROXIMAL AUGUMENTATION: Normal - Valvular incompetence
DISTILL AUGUMENTATION: Normal - Valvular incompetence
DEEP VEIN THROMBOSIS: Absent - present
LEGS (DOPPLER)
Color and duplex Doppler of both the lower limbs were done.
Femoral, popliteal, tibial and superficial vessels were examined.
Arterial flow was seen normal with no evidence of any obstruction.
Veins were seen normal with normal compressibility and flow.
Normal response of proximal and distil agumentation was seen with no
evidence of any valvular incompetence or DVT.
CAROTIDS
Color Doppler of both Carotids
CCA, ECA, ICA and Both VERTEBRALS:
FOCAL MASS: Present - Absent
LOCALIZED DILATATION: Present - Absent
ATHEROMATOUS PLAQUE: Present - Absent
BOTH CAROTIDS and its branches
SYSTOLIC FLOW: Normal – Increased –Decreased
DILASTOLIC FLOW: Normal – Increased –Decreased
VERTEBRAL VESSELS
FLOW REVERSAL: Present – Absent
CAROTIDS
Color and duplex Doppler of both the carotids was done.
CCA, ECA and ICA and both the vertebrals were examined.
B- Mode scan showed no focal mass, localized dilatation or atheromatous
plaque.
Doppler flow samples showed normal systolic and diastolic flow in both the
carotids and its branches with no stenosis or obstruction.
Both the vertebrals showed normal flow with reversal.
