Page 1
RIGHT LEFT
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Prior Study Dates: US:_____________ CT:______________ MR:___________________Other:____________________________
ULTRASOUND FINDINGS Organ NOT
VIS NL ABNL Comments
LIM
ITE
D R
UQ
Liver CC Length: _______________ cm
MPV:__________mm Hepatopetal
Biliary Ducts
Gallbladder Gallstones: Yes No
Polyps: + Murphy’s: Yes No
Pericholecystic Fluid: Yes No
Wall Thickness: __________ mm
Spleen Length: cm
Pancreas
Aorta P: x M: x D: x cm
IVC
Right
Kidney
Left
Kidney
Comments:
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
Abdominal Ultrasound
RI_______
RI_______
RI_______
______RI
______RI
______RI
(L) ____________ (H) ___________ (W) ____________ (cm)
CBD: _________________ mm
(L) ____________ (H) ___________ (W) ____________ (cm)
Kidney & Hypertension Center PC
Page 2
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Prior Study Dates: US:______________ CT:_________________ MR:_______________________ Other:____________________________
ULTRASOUND FINDINGS NOTVIS NL ABNL
AP VIEW LATERAL VIEW
Prox
________ x ________ cm
Mid
_________x _______ cm
Distal
________ x ________ cm
Bifurcation
________ x ________ cm
Right Iliac
________ x ________ cm
Left Iliac
________ x ________ cm
Comments:
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
Aorta - Vascular Kidney & Hypertension
Center PC
Page 3
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Prior Study Dates: US:____________ CT:_____________ MR:_________________________Other:________________________
ULTRASOUND FINDINGS
□ Appendix Visualized □ Not Seen
□ Appendix Diameter_______________mm
Abnormal > 6mm: sensitivity 100% / specificity 64%
Abnormal > 7mm: sensitivity 94% / specificity 88%
□ Noncompressable □ Single Wall Thickness _____________________mm (Abnormal ≥ 2 mm)
□ Appendicolith(s): Size:_________________________________________________
□ Focal Tenderness over Appendix (McBurney Sign)
□ Abscess (L)_________________x (H)_____________________x (W)_____________________cm
□ Hypervascularity
□ Surrounding Edema Phlegmon
□ Lymphadenopathy
□ Distal Ileum Abnormal
□ Ascites
□ Right hydronephrosis
OTHER:
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
Appendix Ultrasound Kidney & Hypertension Center PC
Page 4
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Prior Study Dates: US: CT: MR: Other:
ULTRASOUND FINDINGS
Bladder: □ Normal
□ Abnormal
Ureteral Jets:
Bilat Right Left
Pre Void:______________cc Post Void:______________cc
Prostate:
(L)_____________x (H)______________ x (W)______________cm Volume:________________cc
Other:
COMMENTS:
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
Bladder Ultrasound Kidney & Hypertension Center PC
Page 5
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Prior Study Dates: US: CT: MR: Other:
ULTRASOUND FINDINGS Organ
NOTVIS
NL ABNL Comments
R
E
N
A
L
Right Kidney
Renal Pelvis: _________________mm
Left Kidney
Renal Pelvis: _________________mm
Bladder Ureteral Jets: Bilat Right Left
Pre Void:_________________ cc Post Void:_________________ cc
Other:
Comments:
RIGHT LEFT
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
RI
RI
RI
RI
RI
RI
Pediatric Renal
Ultrasound
RENAL PART Please use symbols below to identify
Calc
Mass
Cyst
RENAL PART Please use symbols below to identify
Calc
Mass
Cyst
Hydro Hydro
(L) ____________ (H) ___________ (W) ____________ (cm)
(L) ____________ (H) ___________ (W) ____________ (cm)
Kidney & Hypertension Center PC
Page 6
Right Kidney
Months Years
Left Kidney
Months Years
Patient Name:_________________________________________________Age:__________ID#___________________Study Date:__________________ Reason for Exam: ___________________________________________________________________________________________________________________ _______________________________________________________________________________________________________Sonographer:__________________ Previous Studies: US: ________________________ CT: ____________________ MR: _________________________ Other: _________________
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
PEDIATRIC RENAL LENGTH MEASUREMENT
Kidney & Hypertension Center PC
Page 7
RI
formatting
of
the
pull
q
formatting
of
the
pul
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Prior Study Dates: US:_US: CT: MR: Other:
ULTRASOUND FINDINGS Organ
NOTVIS
NL ABNL Comments
Aorta P: x M: x D: x cm
R E N A L
Right Kidney
Left Kidney
Other:
Comments:__________________________________________________________________________________________________________
_______________________________________________________________________________________
RIGHT LEFT
PEAK SYSTOLIC VELOCITY MEASUREMENTS IN THE RENAL ARTERIES
AORTA PSV_________________cm/sec
RENAL ARTERY PSV (cm/sec)
RAR (Renal Artery to
Aorta Ratio):
RENAL ARTERY PSV (cm/sec)
RAR (Renal Artery to
Aorta Ratio):
RA Origin: Right: RA Origin: Left:
Mid RA: Right: Mid RA: Left:
Renal Hilum: Right: Renal Hilum: Left:
Reference Data: > 60% stenosis ; RAR > 3.5 : 1 ; Renal artery PSV >180 cm/sec
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
RI
RI
RI
RI
RI
Renal Artery
Doppler Ultrasound
formatting
of
the
pull
quot
RENAL PART Please use symbols below to identify
Calc
Mass
Cyst
Hydro
RENAL PART Please use symbols below to identify
Calc
Mass
Cyst
Hydro
(L) ____________ (H) ___________ (W) ____________ (cm)
(L) ____________ (H) ___________ (W) ____________ (cm)
Kidney & Hypertension Center PC
Page 8
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Previous Study Dates: US: CT: MR: Other:
ULTRASOUND FINDINGS Organ
NOTVIS NL ABNL Comments
RETROPERITONEUM
Pancreas
Aorta P: x M: x D: x cm
IVC
R E N A L
Right Kidney
Left Kidney
Bladder Ureteral Jets: Bilat Right Left
Pre Void: cc Post Void: cc
Prostate
Other:
Comments:__________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
RIGHT LEFT
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
RI
RI
RI
RI
RI
RI
Renal or Retroperitoneal
Ultrasound
RENAL PART Please use symbols below to identify
Calc
Mass
Cyst
RENAL PART Please use symbols below to identify
Calc
Mass
Cyst
Hydro Hydro
(L) ____________ (H) ___________ (W) ____________ (cm)
(L) ____________ (H) ___________ (W) ____________ (cm)
(L)__________x (H)___________ x (W)__________cm Volume:______________cc
Kidney & Hypertension Center PC
Page 9
Thyroid Ultrasound
Patient Name: Age: ID# Study Date:
Reason for Exam: Sonographer:
Prior Study Dates: US: CT: MR: Other:
PREVIOUS BIOPSY? □YES □ NO IF YES, WHICH SIDE? □ RIGHT □ LEFT
PROCEDURE REPORT ATTACHED: □YES □ NO BIOPSY/LAB RESULTS ATTACHED: □YES □ NO
COMMENT: _____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
RISKS: Personal Hx Thyroid CA? □YES □ NO Family Hx Thyroid CA 1º? □YES □ NO
Neck SRT as Child? □YES □ NO Positive PET Scan? □YES □ NO
Please use symbols below to identify
Calc
Mass Cyst
Complex
Comments:
ULTRASOUND FINDINGS
Right Lobe Isthmus Left Lobe
Size:
(L) (H) (W) (cm)
Size:
____________________mm
Size:
(L) (H) (W) (cm)
Nodules (size in mm): Nodules (size in mm): Nodules (size in mm):
Right Lymph Nodes Left Lymph Nodes
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017
Kidney & Hypertension Center PC
Page 10
Patient Name: Age: ID# Study Date:
Reason for Exam:
Sonographer:
Prior Study Dates: US: CT: MR: Other:
Lesion Description Location Current Size Previous Size
Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.11 Revised 2.2016
ULTRASOUND
WORKSHEET
Kidney & Hypertension Center PC