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

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

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

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

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

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

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

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

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

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