NUC RAD SHARE

RADIOLOGY DICTATIONS

 
dictation templates

BONE DICTATION SAMPLE/TEMPLATE 

 

 

SINUS/FACIAL SERIES

 

FINDINGS: PA, Waters, and lateral views of sinuses were obtained.  [PA, Caldwell, Waters, Townes, and lateral facial series was obtained].  Paranasal sinuses appear well pneumatized without air-fluid level or significant opacification.  No nasal septal deviation. Orbital rim and nasal bone appear normal.  No displaced fracture or destructive calvarial lesion.  Maxilla, mandible (symphysis / parasymphysis / body / angle / ramus / coronoid process / condyle / subcondylar), and zygomatic arch are normal.  No periapical lucency along root of [incisor, canine, premolar, molar] tooth.

 

IMPRESSION: No radiographic evidence for sinusitis.  Please note that CT is more sensitive and specific study.   

 

NASAL SERIES

 

FINDINGS: No displaced nasal fracture.  Nasal septum is midline.  Normal nasofrontal suture, ethmoidal groove (for nasociliary nerve), and nasomaxillary suture.

 

IMPRESSION: Normal nasal series.  CT scan is more sensitive study.

 

SHUNT SERIES

FINDINGS: VP shunt series was obtained.  Intracranial/ventricular portion of shunt catheter [is not well visualized], reservoir/valve, and distal shunt catheter appears normal.  [A short-segment radiolucent portion of catheter just distal to reservoir cannot be assessed on plain film].  Catheter tubing is seen coursing along [left/right] neck and body wall, [looping within abdomen] with tip terminating within [quadrant of abdomen/pelvis].  No catheter disconnect/discontinuity or kinking.

 

IMPRESSION: No radiographic evidence for VP shunt malfunction. 

 

NECK SOFT TISSUE

 

FINDINGS: Soft tissue AP and lateral views of neck shows patent airways without focal narrowing or ballooning of hypopharynx.  Epiglottis and aryepiglottic folds are normal.  No subglottic narrowing or steeple sign.  No enlarged adenoids or palatine/lingual tonsils.  Retropharyngeal soft tissues are unremarkable.   

 

IMPRESSION:  Normal soft tissue Xray.

 

TMJ SERIES

 

FINDINGS: AP and open/closed mouth lateral oblique views of temporomandibular joints (TMJ) are submitted.  Bilateral mandibular condyle heads are normal in appearance and well placed within temporomandibular fossa on closed mouth views.  Open mouth views demonstrate normal anterior translation of mandibular condyle just underneath the articulate eminence. No joint space loss to suggest articular disc injury or degeneration.

 

IMPRESSION: normal radiographic appearance of bilateral TMJ.  MRI may be considered if symptoms persist.

 

 

SHOULDER

FINDINGS: internal/external rotation AP view including axillary, scapular-Y, and grashey projections are submitted

 

AC JOINTS

 

FINDINGS: AP views of bilateral AC joints without and without weight bearing demonstrate normal acromioclavicular and coracoclavicular distances without fracture, dislocation, or significant degenerative changes.

 

FRACTURE

 

FINDINGS: [acute/subacute] [open/closed] [intra-articular] [mild/mod/severely comminuted] [incomplete/avulsion/transverse/oblique/spiral/longitudinal/segmental/impacted/torus or buckle/greenstick/pathologic] fracture. [Disarticulation]. [Segmental bone loss]. [Pulverized]. [Mangled].

 

[with deg apex x angulation] [non-displaced] [mm or shaft width or 100% displacement/translation of distal fx fragment] [mm foreshortening or bayonette apposition/overriding] [distracted] [with interposed butterfly fragment] [fracture-dislocation] [articular step-off or incongruity].

 

There is avulsion fracture at [volar/dorsal plate] involving [% of articular surface] with [mm proximal or no sig displacement of fx fragment] and/or [mild articular incongruity]. 

 

IMPRESSION: []

 

FRACTURE FOLLOW-UP

 

FINDINGS: [] views of [] are submitted [in fiberglass or plaster cast/splint which obscures fine anatomic details] [out-of-cast/splint].  [Disuse osteopenia].

 

Patient is s/p closed reduction with [adequate restoration of anatomic] [improved] [near-anatomic] alignment. 

 

Patient is s/p open reduction internal fixation (ORIF) with [fixation plate and screws or fixation hardware] providing [appropriate/near anatomic] alignment. External fixation device in place (above and below fx site) with pins/screws connected to external fixation rods via clamps.

 

Screw extends [x] mm beyond the margins of [location] cortex.  The [location] screw has partially backed out [x] mm with screw head now protruding into adjacent soft tissue [and may be source of patient’s discomfort]. Perihardware lucency.

 

Alignment and configuration of fracture remains unchanged compared to [Xray].  [Correlate for expected post-op outcome]. 

 

There has been interval [increasing sclerosis at fracture site] [periosteal new bone formation] [immature/mature callus] [bridging osseous callus] [obliteration of fracture lucency] suggesting continued healing and remodelling.  Appropriate osseous union without residual fracture lucency. Fracture margins are ill-defined suggesting resorption or hyperemia associated with early inflammatory/reparative process. Fracture lucency remains partially visible.  Fracture cleft is still visible.  Healed fracture with mild residual deformity.  Mal-united/un-united fracture (>6mos).  Mal-union/non-union.

 

Reconstruction of [site] with osteotomy and intervening [iliac] bone graft along with fixation hardware providing [improved/anatomic] alignment. Incorporation of bone graft at osteotomy site.

 

IMPRESSION: [Continued][early] healing [] fracture [with unchanged alignment and configuration compared to Xray] [in near anatomic alignment]. 

 

Fracture follow-up showing stable alignment with [progression of bony healing][early/advanced partial healing].  Fracture follow-up showing no significant interval change. 

 

Healed fracture in appropriate anatomic alignment without evidence of mal-union/non-union.

 

No hardware complication. [Correlate for expected post-surgical outcome].  

No radiographic evidence for acute or healing fracture.

 

HIP

 

FINDINGS: AP view of the pelvis with [L/R] hip in neutral position along with dedicated frogleg lateral projection are submitted. [ ] views of [L/R] hip with template for pre-operative planning.

 

There is [coxa profunda] or acetabular [retroversion][overcoverage] seen with PINCER-type FAI.  Dysplastic bump at lateral femoral head-neck junction seen with CAM-type FAI.  Small calcific density along superolateral acetabular rim likely represents sequel of chronic labral impaction injury vs os acetabuli.  Tiny luceny with sclerotic rim within femoral neck most likely fibrocystic lesion or heniation pit.

 

[Mild/moderate/sig/exuberant] periarticular osteophytosis with subchondral sclerosis and [prominent] geode formation along with [predominantly superior joint space loss][bone-on-bone appearance].  There is associated [flattening][remodeling] of femoral head articular surface.  Serpiginous subartiacular sclerosis of femoral head suggestive of AVN.  Axial migration of femoral head with acetabular protusio.  Coxa [varus/valgus deformity]. Enthesopathic changes along greater trochanter.  [size] pst-traumatic/dystrophic ossification contiguous with [] seen along [].

 

 

ANKLE

 

FINDINGS: 3 [non] weight bearing views of [L/R] ankle demonstrate [lateral/medial] ankle STS with [mild/mod/sig] joint effusion but no acute fracture consistent with [medial/lateral] ankle sprain.  Ankle mortise is intact.  No focal subchondral lucency at talar dome to suggest osteochondral injury.  No achilles/plantar calcaneal spur.  No significant degenerative changes.  Incidental note of os trigonum or steida process.

 

There is [transverse/oblique] fracture of lateral malleolus [below/at/above] tibiotalar joint with [out] [lateral clear space widening >5mm consistent with syndesmotic disruption].  There is associated [medial malleolar fracture] or [medial ankle joint widening >4mm suggestive of deltoid ligament disruption]. Widened ankle mortise.

 

[Bimalleolar fx] [Trimalleolar fx] [Pilon fx with comminuted distal tibia] [Tillaux fracture involving anterolateral tibia] [Triplane fx in skeletally-immature patient] [Recommend dedicated tib-fib Xray to exclude proximal fibular fracture or Maisonneuve’s]

  

FOOT

 

FINDINGS: 3 [non] weight bearing views of [L/R] foot demonstrate [mild/mod/severe] hallux valgus deformity with overgrowth of medial aspect of 1st MT head with overlying ST prominence consistent with bunion formation.  Also, bunionette at 5th MTP.  Degenerative changes of [midfoot] [1st MTP].  Dorsal spurring at calcaneonavicular joint.  Achilles/plantar calcaneal spurs.  There is pes [planus][cavus]. Os trigonum, normal variant.  Fixed flexion deformity of [digit at x joint] suggestive of hammer toe.

 

FOOT post-op

 

FINDINGS: [Single] K-wire traverses [x] ray extending percutaneously from distal tuft across IP/MTP jts with tip at [] providing good anatomic alignment s/p [hammer toe repair] with [resection arthroplasty at x joint]. Interval removal of K-wire with [appropriate/expected] fusion/arthrodesis at [joints].

 

Patient is s/p [bunionectomy] [hallux valgus correction] with [a single screw] seen across [proximal/distal] 1st metatarsal osteotomy site with [no significant residual] hallux valgus deformity. Patient is s/p Lapidus procedure with proximal osteotomy and surgical arthrodesis of 1st TMT joint with hardware. 

 

Osseous margins at the osteomy site are sharp without significant osseous union at this time.  No evidence for hardware complication.  

 

BONE AGE

 

FINDINGS:  A single AP view of the left hand is submitted. The patient's chronological age is [] years and [] months.  Using the "Radiographic Atlas of Skeletal Development of the Hand and Wrist" by Greulich & Pyle, bone age is assessed to be approximately [] years and [] months.  Standard deviation for variability in skeletal age per Brush Foundation study is [] months.

 

IMPRESSION:  [Normal/delayed/accelerated] skeletal maturation with bone age [within/below/greater than] 2 standard deviations of skeletal age.

 

SCOLIOSIS

 

FINDINGS: [AP and lateral] standing scoliosis survey is obtained.  [dextro/levo] curvature of the [thoracic] spine with [] degree Cobb angle measured from the superior end-plate of the [] vertebral body and the inferior end-plate of the [] vertebral body.  There is [secondary/compensatory] [dextro/levo] [roto] curvature of [lumbar] spine with [] degree Cobb angle measured from [] to [].  [No exaggerated thoracic kyphosis or lumbar lordosis]. [No vertebral anomalies].  [#] ribs noted.  [No pelvic tilt].  [25/50/75/100%] of iliac apophyses is ossified and is [closed/open or fused/unfused]. [Congenital block vertebrae].

 

IMPRESSION: [No significant scoliosis]. [Consider scanogram for possible leg length discrepancy].

 

SCANOGRAM

 

FINDINGS: A [CT scanogram image] [standing full-length AP radiograph of lower extremities] is obtained [for pre-op planning].  [A scanogram was obtained of lower extremities with 3 separate exposures centered at bilateral hip, knee, and ankles]. 

 

Leg length is measured from the proximal end of femoral head to the center of tibial plafond.  Left leg measures []mm and the right leg []mm with a difference of []mm.

 

Angle btwn femoral mechanical axis (drawn from center of femoral head to intercondylar notch) and tibial mechanical axis (drawn from center of tibial plateau to center of tibial plafond) is xdeg varus/valgus on the right and ydeg varus/valgus on the left. (Note: angles reported as deviation from 180; neg are varus=apex lateral; and pos are valgus=apex medial)

 

IMPRESSION: [No significant leg length discrepancy].  [Leg length discrepancy as above].

 

C-SPINE

 

FINDINGS: [3/5] views of cervical spine were obtained.  Vertebral body height and alignment is normal.  No significant disc space narrowing or other degenerative changes.  Osseous neuroforamina are patent.  Predental space and prevertebral soft tissues are normal.  Visualized lung apices are unremarkable.

 

C7-T1 vertebral junction is not well-visualized on lateral projection.  Limited open-mouth odontoid view due to [technique] [overlying dentition or dental amalgam].  Straightening of normal cervical curvature may be due to muscle spasm/strain.  Multilevel uncovertebral hypertrophy.  Anterior longitudinal ligament calcification is noted at adjacent to [].  Dystrophic nuchal ligament calcification.  Incidental note of cervical ribs or symmetrically prominent/elongated C7 transverse processes.  

 

IMPRESSION: []

 

C-SPINE POST-OP

 

FINDINGS: [3/5] views of C-spine were obtained.  Patient [is status post] [has had prior] anterior cervical discectomy and fusion (ACDF) from [C3] to [C6] level.  No interval change in hardware alignment or configuration.  No perihardware lucency or interbody graft migration.  [Interbody graft or metal cage is appropriately incorporated with intervertebral osseous fusion].  Interbody graft or markers are noted [without significant][with incomplete / partial] intervertebral osseous fusion [at this time].  Minimal residual spondylolithesis at [] is likely expected post-operative outcome. 

 

[Disc replacement hardware or disc implant in place.]

 

IMPRESSION: No cervical spinal fusion hardware complication.  Correlate with expected post-operative outcome. 

 

L-SPINE

 

FINDINGS: [3/5] views of the lumbar spine were obtained.  5 non-rib bearing lumbar vertebral bodies.  Vertebral body height and alignment is normal.  No degenerative osteophytosis, facet arthropathy, or disc height loss.  No pars defects/spondylolysis or spondylolisthesis.   

 

6 non-rib bearing lumbar-type vertebral bodies [with the most inferior vertebral body labeled as L6 for purposes of this dictation] [with most superior vertebral body presumed to represent T12 with hypoplastic ribs].  Transitional anatomy at lumbosacral junction with [lumbarized S1] [sacralized L5] [partially sacralized L5 with pseudoarthrosis or left/right L5 transverse process with adjacent S1 segment] which can be symptomatic due to altered biomechanics. 

 

[Straightening of lumbar curvature may be due to muscle spasm/strain]. [Mild/mod/sig] [multilevel] degenerative changes with osteophytosis, end-plate sclerosis and schmorl’s node formation worst at [level] along wtih [mild/mod/sig] disc height loss.  [Mild/mod/sig] [left/right] [level] facet sclerosis/hypertrophy/arthropathy. 

 

There is age-indeterminant [mild/mod] [level] [%] anterior wedge compression deformity.  Minimal anterior vertebral height loss at thoracolumbar junction is likely physiologic sequela of chronic axial loading.  []mm antero/retro listhesis of [] on [] with/without pars defects. 

 

Congenitally unfused transverse processes at L1.  Posterior spinal fusion defect at [].  [Multilevel enlargement and apposition of adjacent spinous processes with reactive sclerosis consistent with Baastrup’s disease]. 

 

[Bilateral inferior SI joint degenerative changes without abnormal SI sclerosis to suggest sacroilitis].  [Sacral arches are intact]. Presumed pelvic phleboliths.   

 

IMPRESSION:

1. Multilevel [mild/mod/severe] DDD worst at [] with/without disc height loss.  [] facet arthropathy.

2. Multilevel [mild/mod] DJD without significant disc height loss.

3. If radicular symptoms, consider further evaluation with MRI.

 

L-SPINE POST-OP

 

FINDINGS: [3/5] views of L-spine were obtained.  Patient has had prior non-instrumented laminectomy and posterior spinal decompression at [].  Patient [is status post] [has had prior] instrumented interbody fusion with posterior spinal rods and pedicular screws at [L3 thru S1] levels.  No interval change in hardware alignment or configuration.  No perihardware lucency, hardware fracture, or interbody migration.  [Interbody graft or metal cage is appropriately incorporated with intervertebral osseous fusion].  Interbody graft or markers are noted [without significant][with incomplete / partial] intervertebral osseous fusion [at this time].  Minimal residual spondylolithesis at [] is likely expected post-operative outcome.  [Interval worsening degenerative changes at [] adjacent to spinal fusion is suggestive of transitional syndrome due abnormal biomechanics].

 

IMPRESSION: No lumbar spinal fusion hardware complication.  Correlate with expected post-operative outcome.

 

CT C-SPINE

 

COMPARISON: []

 

TECHNIQUE: Non-contrast CT cervical spine was performed at []mm collimation from skull base thru thoracic inlet without IV contrast [with patient in C-collar].  Sagittal and coronal reformats were obtained.

 

FINDINGS:

 

No acute fracture.  No prevertebral soft tissue swelling. Atlanto-occipital and atlanto-axial articulation is normal.  Atlanto-dental distance is normal.

 

Cx-Cy: Vertebral height and intervertebral disc space is maintained.  No spondylolisthesis.  No neuroforaminal narrowing.  No facet hypertrophy.  Productive degenerative changes lead to [min/mild/mod/severe] central canal stenosis.

 

IMPRESSION: []

 

SKELETAL SURVEY

 

COMPARISON: []

 

TECHNIQUE: Osseous survey includes [AP/lateral skull, PA/lateral chest along with oblique rib series, AP/lateral cervical/thoracic/lumbar spine, AP pelvis, AP/lateral humeri/forearms, and AP/lateral femurs/tibia/fibula].

 

FINDINGS: [Osseous mineralization is normal].  [Generalized osteopenia].

 

Skull: []

Chest/ribs: []

Spine: []

Abdomen/Pelvis: []

Upper extremities: []

Lower extremities: []

 

IMPRESSION: [No focal lytic lesion]. [Degenerative changes as above].

 

INTRA-OP FLUORO

 

FINDINGS/IMPRESSION: [Intra-operative] fluroscopic support was provided for [department] [Dr].  [Number] [unlabeled] [collimated] fluoro spot images of [location] were obtained which demonstrate [instrument tip pointing to posterior L5-S1 intervertebral level].  Total fluoro time of [].  Please see operative/procedure report for details.

 

Intra-op fluoro support. X spot images were stored. Total fluoro time of X min. See op-report for details.

 

JOINT DJD

 

FINDINGS: There are [mild/moderate/severe] degenerative changes characterized by [small/bulky/exuberant] periarticular osteophyte formation, subchondral sclerosis, [prominent] geodes, [mild/mod/severe] joint space narrowing/loss [with bone-on bone appearance], and [articular surface remodeling]. [No] effusion or joint loose bodies.  Enthesophatic changes are noted.  Osseous mineralization is normal. [coxa/genu] [varus/valgus] deformity.

 

IMPRESSION: [stable/chronic] [mild/moderate/severe] DJD without acute findings.

 

ARTHROPLASTY

 

FINDINGS: [Total][unipolar/bipolar hemi-][unicompartment hemi-][hip/knee] [cemented] arthroplasty hardware stable in alignment and configuration without abnormal lucency at [hardware-osseous] [cement-hardware] interface.  No peri-hardware heterotopic bone formation.  No significant retained osseous fragment.  No ossified joint loose bodies. 

 

[Baseline exam status post arthroplasty shows radiolucent zone likely due to poor cement packing, normal fibrous tissue 1-2mm or movement of prosthesis before cement has polymerized.]

 

Complications:

[Periprosthetic fracture] [Intraop fx vs control perforation during revision reduced with cerclage cables]

[Cement extrusion (intrapelvic thru medial acetabulum)] [cement fracture or fragmentation]

[Component wear due to poor positioning]

[Component migration (loosening) radiolucent zone at interface >2mm] [Tilting or cranial/medial migration of acet component] [abnormal lateral inclination of acet component nl 30-50deg] [varus/valgus positioning of fem stem] [fem head component eccentrically located within acet cup] [Polyethelene liner/spacer of acetabulum: wear or dislocation with eccentric position of femoral head] [subsidence (sinking) of component]

[Hardware dislocation]

[Heterotopic ossification]

[Lucency at medial femur (near lesser troch)=calcar resorption][Luceny at lateral femur (near gr troch)=stress sheilding]

[Particle disease] [Osteolysis (aggressive granulomatosis)]

[Non-union of greater trochanter osteotomy]

[Broken or frayed cerclage wire/cable]

[Cortical thickening (stress fx due to altered biomechanics) or abnl cortical thinning]

[Revision arthroplasty]

[Infection: soft tissue gas, laminated periosteal rxn (rare)]

[s/p hardware removal, placement of abx-impregnanted cement spacers]

 

IMPRESSION: stable [knee/hip] hardware without radiographic evidence for complication.

 

HAND ARTHRITIS

 

FINDINGS: [3] standard views of bilateral hands along with ball-catcher’s projection were obtained. 

 

OA=There is [mild/mod] periarticular osteophytosis, subchondral sclerosis/geode formation and [mild/mod] joint space narrowing primarily involving [DIP and 1st CMC] joints.  These changes are worst at [] joint.  No periarticular osteopenia, joint erosions, periostitis, or significant deformity.  Bouchard (PIP) and Heberden (DIP) nodes are noted.  Mild subluxation at 1st CMC joint. 

 

RA=There is diffuse periarticular osteopenia with periarticular marginal erosions seen at [several MCP joints and at ulnar styloid tip].  There is joint space loss and ulnar deviations at MCP joints.  Swan neck and Boutonniere’s deformities.  Pattern of involvement is symmetric for both hands.  Extensive destruction, ankylosis, and subluxations.  Rheumatoid nodules.

 

Psoriasis=There is asymmetric predominantly distal involvement with joint space loss without osteopenia, marginal erosions (with mickey-mouse ears), pencil-in-cup deformities, ankylosis, acro-osteolysis, ivory phalanx, and fluffy periostitis.  Diffuse soft tissue swelling of digits (sausage).  Correlation with [pelvis] findings of asymmetric sacroilitis makes seronegative spondyloarthropathy (HLA-B27) likely.

 

 Erosive OA= There is symmetric predominantly distal involvement (PIP and DIP joints) with joint space loss and central erosions with gull-wing deformities and ankylosis.  Also, there are productive changes to include periarticular osteophytosis, subchondral sclerosis/geode formation involving both [DIP and 1st CMC] joints.

 

 CPPD=There is chondrocalcinosis along region of TFCC and radiocarpal joint with joint space narrowing and prominent subchondral cyst formation at the wrist joint.  Beak-like osteophytes at MCP joints.  There is scapholunate interval widening with scapholunate advanced collapse (SLAC).

 

Gout=There is asymmetric [monoarticular] punched out erosions with sclerotic margins and overhanging edges at [].  Relative sparing of joint space and no significant periarticular osteopenia.  Adjacent mass-like soft tissue swelling and scattered calcifications may represent tophus formation.

 

IMPRESSION: [mild/mod/sig] osteoarthritic changes.  Findings concerning for inflammatory arthritis; correlation with serum markers is suggested.

 

BONE TUMOR

 

FINDINGS:

[size] [expansile]

[well-circumscribed/marginated/ill-defined] with [narrow/wide] zone of transition    [epiphyseal/metaphyseal/diaphyseal/juxtacortical/juxtaarticular/intramedullary]

[sclerotic/lucent/lytic/moth-eaten/permeative/lucent with thin or well-defined sclerotic rim]

[amorphous/cloud-like, arc/swirls, GG] matrix

No associated [endosteal scalloping, periosteal rxn, cortical disruption, or any discernable ST component]

 

IMPRESSION: aggressive or non-aggressive osseous lesion.

 

POST-OP BONE TUMOR SURGERY

 

FINDINGS: patient is status post [enucleation] [curettage] [cementing with polymethylmethacrylate (PMMA)] of prior [osseous tumor] within [location]. Overall appearance is unchanged from prior studies with no focal lytic lesion or absence of sclerotic rim at bone-cement interface to suggest recurrence. 

 

IMPRESSION: Stable post-op changes with no radiographic evidence for recurrence. 

 

SACRUM/COCCYX

 

FINDINGS: sacrococcygeal alignment is normal.  No widening of synchondrosis or abnormal angulation.  Sacral arches and SI joints appears normal.

 

IMPRESSION: no acute osseous injury.

 

 


NORMAL DICTATION TEMPLATE BONE PLAIN FILMS ARTHRITIS ARTHROPLASTY SKELETAL SURVEY POST OP SPINE SCANOGRAM BONE AGE SINUS SHUNT TMJ SERIES SCOLIOSIS SACRUM FRACTURE HEALING NASAL 

.


FLUORO DICTATION SAMPLE/TEMPLATE 

 
 

 

UGI

FINDINGS:  The patient swallowed barium and effervescent granules [without difficulty or aspiration].

The oral and pharyngeal phases of swallowing are normal. Triggering of swallowing reflex is normal/delayed.  Oral transfer is normal.  Pharyngeal coordination is normal without nasal regurgitation, laryngeal penetration or subglottic/tracheal aspiration.  Cough reflex was/was not elicited.  Contrast is cleared from hypopharynx after swallowing without pooling of contrast within vallecula or pyriform sinuses.  Cricopharyngeal muscle relaxation is normal (no cricopharyngeal muscle hypertrophy or achalasia).  No posterior pharyngeal thickening (ie no edema/hematoma/abscess).

Normal esophageal mucosa and motility.  No intrinsic or extrinsic lesions.  No hiatal hernia.  No gastroesophageal reflux is demonstrated during this exam despite maneuvers to elicit reflux.  Normal transit of a 13mm barium pill through esophagus into stomach without difficulty.

Normal gastric mucosa and folds.  Normal duodenal bulb.

IMPRESSION: Normal [esophagram] [UGI].

LEAK STUDY

FINDINGS:  Patient is status post [surgery].  Single contrast leak study was performed in [upright] position.  Patient was given a small amount of water to exclude aspiration.  Preliminary image over the abdomen shows [post-op changes from recent surgery].  Small amount of water-soluble contrast (Gastrograffin) was given [orally] [via tube] [followed by thin barium].  No evidence for contrast extravasation to suggest leak.  [Contrast transits across anastamosis without delay.  Minimal/mild narrowing at anastamotic site likely represents expected post-operative edema.]  [Subsequently, limited CT scan was performed across anastomotic site to exclude any subtle contrast extravasation].

IMPRESSION: No evidence for post-operative leak [at anastamosis site].   

SBFT

FINDINGS:  Scout image demonstrate [normal bowel gas pattern].  Single contrast SBFT was performed with thin barium.  Multiple sequential overhead images were obtained along with intermittent fluoroscopic examination.  The small bowel is [of normal course and caliber]. Jejunal and ileal mucosal fold are normal.  No intrinsic or extrinsic mass lesions are identified. The transit time from stomach to cecum is []hr []min which is within normal limits. The terminal ileum appears normal. 

IMPRESSION: Normal SBFT.

MODIFIED ENTEROCLYSIS

FINDINGS:  Modified enteroclysis was performed using thin barium and air (for double contrast imaging of small bowel) via an 8fr feeding tube placed under fluoroscopic guidance with tip [near/distal to] ligament of Trietz.  Approximately []cc of thin barium was given.  Intermittent fluoro images were obtained [along with multiple sequential overhead images].  Scout image obtained prior to exam demonstrates [].  The small bowel is [of normal course and caliber]. Jejunal and ileal mucosal fold are normal.  No intrinsic or extrinsic mass lesions are identified. The terminal ileum appears normal.  The transit time from proximal jejunum to cecum is []hr []min which is within normal limits.

IMPRESSION:  Normal double contrast (modified enteroclysis) imaging of small bowel.

RYGB

FINDINGS:  Patient is status post [RYGB].  [single/double] contrast fluoroscopic imaging was performed with [water-soluble contrast][barium].   No contrast extravasation to suggest leak.  Esophagus and the gastric remnant are normal in appearance.  Gastrojejunal anastamosis is normal without [stricture/ulceration/leak].  [Mild narrowing at gastrojejunal anastamosis most likely represents expected post-surgical mucosal edema].  Contrast transits from gastric remnant to efferent loop without delay.  Efferent loop is unremarkable without stricture or dilatation.  Jejunojejunal anastamosis is unremarkable.  No retrograde filling of afferent loop.  [No afferent loop dilation to suggest possible afferent loop syndrome].    

IMPRESSION:  Normal [single/double] contrast evaluation s/p [RYGB].

FUNDOPLICATION

FINDINGS:  Patient is status post [Nissen/Toupet fundoplication] [Hill/Collis gastropexy].  [single/double] contrast fluoroscopic imaging was performed with [water-soluble contrast][barium].  No contrast extravasation to suggest leak.  There is expected post-operative narrowing at site of fundoplication along with pseudodefect at gastric cardia.  No evidence of slipped fundoplication or gastro-esophageal reflux.  Normal esophageal and gastric mucosa. 

IMPRESSION:  Normal [single/double] contrast evaluation s/p [fundoplication].

DCBE

FINDINGS:  Scout film demonstrates [appropriate bowel prep and unremarkable bowel gas pattern].  Air and barium were introduced retrograde via rectal tube [after digital rectal exam].  Fluoroscopic and over-head spot images were obtained.  The colon is visualized in its entirety. The colonic mucosa and haustral pattern is normal. [No focal narrowing/constricting lesions or polyps are noted].  Reflux is seen into a normal appearing terminal ileum.  Appendix is [not] visualized.  Excess barium was drained out at the end of the exam and the rectal tube was removed.  Post-evacuation image of rectum is normal. 

IMPRESSION: Normal DBCE

HSG

FINDINGS:  Negative pregnancy test was confirmed prior to exam.  Endometrial canal was cannulated with []fr catheter and  []cc of [] was instilled in a sterile fashion.  The endometrial cavity is [normal in contour without any filling defects].  Contrast is seen in the fallopian tubes bilaterally which are [normal in course and caliber]. There is free intraperitoneal spill of contrast bilaterally.

IMPRESSION: Normal HSG (hysterosalpingogram)

VCUG

FINDINGS:  Bladder was catheterized with [5-8]fr feeding tube using sterile technique. Preliminary image demonstrates [normal bowel gas pattern].  []cc of cysto-conray II was instilled under gravity over [] filling cycles.  Fluoroscopic images were obtained over bladder and kidneys during filling and voiding phases.  No evidence for VUR.  No ureterocele is seen during filling phase.  Voiding phase demonstrates normal urethra.  [Minimal] post-void residual volume.

IMPRESSION: Normal VCUG

PEDS UGI

FINDINGS: Single contrast UGI was performed. []cc of diluted water-soluble contrast was administered orally [via bottle].  No aspiration.  Stomach is normal in size.  Pylorus is unremarkable.  Contrast empties promptly into duodenum.  No obstruction of the duodenum.  Ligament of Trietz or duodenal-jejunal junction lies in [normal/abnormal/low] position.  [Incidental note of GER reflux during the exam].

IMPRESSION: No malrotation or duodenal obstruction  

PEDS ENEMA

FINDINGS: Single contrast enema was performed with []cc water-soluble contrast introduced retrograde gently via []fr tube under gravity.  Entire colon was filled.  Colon is normal in size and position.  Rectosigmoid relationship is normal.  Cecum is located in right lower quadrant.  Post-evacuation image shows [].

IMPRESSION: No evidence for Hirschsprung disease, meconium ileus, meconium plug-small left colon syndrome, ileal atresia, or colonic stricture.

ERCP

TECHNIQUE: ERCP was performed by [gastroenterologist].  Using side-viewing endoscope, major papilla was cannulated and water-soluble contrast was injected and multiple fluoroscopic images were saved.  Please see GI report for details regarding intervention performed.  Total fluoro time was []min.

FINDINGS:    There is good filling of the intra and extra hepatic bile ducts. CHD measures []mm, CBD []mm, and pancreatic duct []mm at head and tapers normally distally.  No focal biliary stricture or filling defects are identified. [There is filling of the cystic duct and gallbladder. The gallbladder is grossly normal.]

IMPRESSION: Normal ERCP.

LAP BAND EVAL

HISTORY: POD# [] s/p adjustable gastric lap band placement

FINDINGS: Scout image shows gastric lap band in [proper orientation] with [normal] phi angle. Limited UGI with water-soluble contrast shows prompt contrast transit through the band without pooling within gastric pouch of distal esopahgus. Gastric pouch measures []cm in diameter. Stomal diameter is []mm without evidence for stomal stenosis.  [Gastric pouch is not seen given unadjusted band.] No herniation of distal stomach through the band to suggest [anterior/posterior] prolapsed or symmetric pouch dilation or gastric erosion. No extravasation of contrast.  Reservoir and tubing appear intact.

IMPRESSION: Normal post-op gastric band.

IVP

FINDINGS:  The scout film demonstrates [normal bowel gas pattern and no obvious urolithiasis].

Following uneventful administration of []cc Isovue-370 IV, renal  nephrograms are [prompt and symmetric] bilaterally.  Kidneys are [normal in size, shape, and axis].  There is [no dilatation, filling defect, or abnormal morphology] of the renal calyces or pelvis.   

Ureters are [normal in course and caliber without any filling defects].  Both ureters are visualized in their entirety.  The bladder is [normal in size, shape, and contour].  There is [minimal] post-void residual.

IMPRESSION: Normal IVP.

MODIFIED BARIUM SWALLOW STUDY (MBSS) WITH SPEECH THERAPY

TECHNIQUE: Lateral video fluoroscopy was performed in conjunction with Speech Therapy. Multiple consistencies were used to evaluate swallowing function.

FINDINGS:

Oral phase: Mastication. Bolus formation. Premature spill over. Aspiration before swallow.

Pharyngeal phase: Laryngeal elevation. Epiglottic excursion. Vallecullar / pyriform residue.  Penetration. Aspiration. Cough response.

Esophageal phase: Stricture. Diverticulum. TE fistula.

IMPRESSION: [Moderate] oral and pharyngeal dysfunction. See Speech Pathology report for recommendations.

LUMBAR PUNCTURE

TECHNIQUE: Risks and potential complications were explained and a informed was written consent. Patient was placed on prone position on fluoroscopy table. Back prepped and draped in usual sterile fashion. 1% Lidocaine was used for Local anesthesia.[ L2-3 or L3-4] interspace was localized. Under fluoro guidance, a [22]G spinal needle was advanced along the right paramidline interlaminar space into the thecal space with a single pass. Opening pressure was measured to be [11]cm of water. Approx [12]cc of clear CSF was passively obtained and sent to lab for analysis. Stylet was replaced and the spinal needle was removed. Patient was placed in left lateral decubitus position midway thru CSF collection to help continue CSF flow. Needle was genly removed. No immediate post-procedure complications. Post-lumbar puncture instructions were given.

IMPRESSION: successful LP without immediate complication.

MYELOGRAM

TECHNIQUE: Risks and potential complications were explained and a informed was written consent. Patient was placed on prone position on fluoroscopy table. Back prepped and draped in usual sterile fashion. 1% Lidocaine was used for Local anesthesia.[ L2-3 or L3-4] interspace was localized. Under fluoro guidance, a [22]G spinal needle was advanced along the right paramidline interlaminar space into the thecal space with a single pass. Needle placement was confirmed with passive flow of clear CSF.  Opening pressure was measured to be [11]cm of water. []cc CSF was collected and sent to lab for analysis. [12cc] of [] was introduced into thecal sac.  Subsequently, CT scan was performed from [T12-S1]. No immediate post-procedure complications.

IMPRESSION: successful lumbar myelogram without immediate complication.  Please see CT myelogram report for imaging details.

JOINT ARTHROGRAM/INJECTION

PROCEDURE: Risk/benefits and potential complications were explained and a written consent was obtained. [R/L] [hip/shoulder] was prepped in a usual sterile fashion.  1% Lidocaine was utilized for local anesthesia.  Under direct pulsed 

fluoro-guidance, a 22G needle was directed into [hip/shoulder] joint. A small amount of non-ionic contrast (Conray) was used to confirm needle placement. Subsequently, [60-80mg Kenalog along w/ 1-1.5cc of 2% Xylocaine] [2cc (20mg) Hyalgan] [xcc of 1/200 diluted Gad (Magnevist) mixture (also containing 3cc of 2% Xylocaine)] was injected.  Needle was removed and the injection site was cleaned and dressed.  Patient tolerated procedure well without immediate complication. Total pulsed fluoro time was []min.

IMPRESSION: Successful [R/L] [hip/shoulder] [intra-articular steroid/hyalgan injection] [arthrogram for intra-articular Gad placement].  [Please see separate MR Arthrogram report].

NORMAL DICTATION TEMPLATE REPORTS ARTHROGRAM MYELOGRAM LP UGI SBFT LEAK STUDY BARIUM ENEMA HSG ERCP DCBE RYGB LAP BAND VCUG 


ULTRASOUND DICTATION SAMPLE/TEMPLATE

 

RUQ

 

COMPARISON: []

 

FINDINGS: Gray scale and color mode imaging of RUQ was performed.  Liver is normal echotexture and size ([]cm in CC dimension).  Gallbladder demonstrates normal wall thickness of []mm without cholelithiasis or pericholecystic fluid.  CBD measures []mm which is normal for age.  Hepatic veins are patent and there is hepatopedal flow within main portal vein.  Right kidney measures []cm in length without hydronephrosis.  Pancreatic body and tail are not well visualized due to adjacent bowel gas.  Negative sonographic Murphy’s.  The left kidney and spleen were not interrogated on this exam.

 

IMPRESSION: Normal RUQ ultrasound without evidence for cholelithiasis or acute cholecystitis.

 

ABDOMEN

 

COMPARISON: []

 

FINDINGS: Gray scale and color mode imaging of abdomen was performed.  Liver is normal echotexture and size ([]cm in CC dimension).  [Non-specific diffuse homogenously increased echotexture of liver resulting in decreased visualization of portal triads which can be seen in setting of diffuse hepatocellular disease most commonly fatty infiltration.]  Gallbladder demonstrates normal wall thickness of []mm without cholelithiasis or pericholecystic fluid.  CBD measures []mm which is normal for age.  Hepatic veins are patent and there is hepatopedal flow within main portal vein.  Right kidney measures []cm and left kidney []cm in length without hydronephrosis.  Spleen in unremarkable (measuring []cm in largest dimension).  Pancreatic body and tail are not well visualized due to adjacent bowel gas.  Negative sonographic Murphy’s.

 

IMPRESSION: Normal abdominal ultrasound without evidence for cholelithiasis or acute cholecystitis.  [Fatty liver.]

 

AORTA

 

COMPARISON: []

 

FINDINGS: Gray scale and color mode imaging of abdominal aorta and bilateral CIA was performed.  AP x Trans measurements are as follow:

Proximal abdominal aorta              []x[]cm

Mid abdominal aorta                       []x[]cm

Distal abdominal aorta                   []x[]cm

Right CIA                                                  []cm

Left CIA                                                     []cm

 

There is [mild/mod] atherosclerotic disease.

 

IMPRESSION: No abdominal aortic aneurysm.  Bilateral CIA appear normal.  [Mild/mod] atherosclerotic disease.

RENAL

 

COMPARISON: []

 

FINDINGS: Gray scale and color mode imaging of kidneys and bladder was performed.  Right kidney measures []cm and left kidney []cm in length.  No renal cortical thinning or abnormal parenchymal ecogenicity.  No hydronephrosis or obvious nephrolithiasis.  Please note that ureters are generally not assessed on ultrasound.  Bladder is well distended with bilateral ureteral jets visualized. 

 

IMPRESSION: Normal renal ultrasound.  No hydonephrosis or ultrasonographic evidence for medical-renal disease. [Mild/mod/severe] [left/right] hydronephrosis with no obstructing stone visualized on ultrasound.

PELVIC

 

COMPARISON: []

 

FINDINGS: Gray scale and color [doppler] imaging of the pelvis was performed via transabdominal and endovaginal approaches.  The uterus is normal in echotexture measuring []x[]x[]cm ([]cc volume).  No focal fibroid.  EMS is homogenous measuring []mm in thickness.  [Nabothian cysts are seen with the cervix.]  Right ovary measures []x[]x[]cm ([]cc volume) and the left ovary measures []x[]x[]cm ([]cc volume).  [Arterial and venous flow is confirmed within both ovaries using spectral waveform analysis.]  No adnexal mass.  No pelvic free-fluid.

 

IMPRESSION: Normal pelvic ultrasound.

HYSTEROSONOGRAM

 

COMPARISON: pelvic ultrasound []

 

FINDINGS: Negative pregnancy test was confirmed prior to exam.  Endometrial canal was cannulated with []fr catheter and balloon was inflated.  Under direct endovaginal ultrasound guidance, [5-10]cc of NS was instilled in a sterile fashion.  The endometrial cavity is adequately distended and demonstrates [].  At the end of exam, catheter balloon was deflated and the lower uterine segment was interrogated which also appears normal.

 

IMPRESSION: Successful hysterosonogram [].

HERNIA

 

COMPARISON: []

 

FINDINGS:  Limited ultrasonographic evaluation of [region of interest] was performed using real-time gray-scale and color mode with and without valsalva maneuvers [in supine and upright positions].  No evidence for focal fascial defect or herniation.  [No peristalting bowel is seen within hernia sac].  Also, no hyperemia or solid/cystic lesion in region of interest.IMPRESSION: No hernia elicited during real-time examination of [region of interest] despite valsalva maneuvers.

 

ASCITES

 

FINDINGS: Limited 4quadrant abdominal ultrasonographic evaluation was performed in supine position for ascites evaluation.  Intra-abdominal solid organs were not interrogated.  There is [minimal/mild/moderate/sig] intra-abdominal [anechoic] ascites.  Largest AP dimension of ascitic fluid within 4 quadrants are as follows: RUQ []cm, LUQ []cm, RLQ []cm, and LLQ []cm.   

 

IMPRESSION: [min/mild/mod/sig] intra-abdominal ascites with largest pocket identified in supine position within [quadrant] measuring []cm in AP dimension located []cm deep from abdominal skin surface.  [IR/inpatient team] notified.  Ultrasonographic support for paracentesis available upon request.

THYROID

 

COMPARISON: []

 

FINDINGS: Gray scale and color mode imaging of thyroid gland was performed.  The right thyroid lobe measures []x[]x[]cm ([]cc volume) and the left thyroid lobe []x[]x[]cm ([]cc volume).  The isthmus measures []cm in AP dimension.  Normal thyroid echotexture without focal nodule.  No glandular hyperemia.   

 

IMPRESSION: Normal thyroid ultrasound without discrete nodule.

THYROID WITH NODULES

 

COMPARISON: []

 

FINDINGS: Gray scale and color mode imaging of thyroid gland was performed. 

 

The right thyroid lobe measures []x[]x[]cm ([]cc volume) and the left thyroid lobe []x[]x[]cm ([]cc volume).  The isthmus measures []cm in AP dimension.  [No glandular hyperemia.]   

 

Thyroid gland is diffusely heterogeneous in echotexture with multiple bilateral nodules.

 

There are [number] discrete/dominant nodules within [right/left] lobe which include: 

 

[]x[]x[]cm [location] [ill-defined/well-circ] [ecogenicity][composition i.e. predominantly solid/cystic or mixed solid/cystic] nodule with [microcalcifications][no significant or minimal internal flow]

 

[]x[]x[]cm cystic lesion with increased thru-transmission containing ecogenic foci with comet-tail artifact (inspissated colloid) consistent with b9 colloid cyst

 

[]x[]x[]cm cystic nodule with solid mural component [with flow] [without flow, suggestive of debris]. 

 

No cervical lymphadenopathy is appreciated adjacent to thyroid gland.

 

IMPRESSION: Multinodular goiter with nodules demonstrating [equivocal or no specific suspicious] sonographic features.  Consider follow-up ultrasound for surveillance vs FNA of dominant nodules if clinical concern.

 

[size] [location] nodule demonstrating suspicious features [] for which FNA is recommended to exclude malignancy.

 

THYROID FNA

 

COMPARISON: []

 

TECHNIQUE:  Risks, benefits, and potential complications were discussed with the patient and a written consent was obtained.  Skin was prepped and draped in a usual sterile fashion.  Local anesthesia was obtained using subcutaneous 1% Lidocaine injection.  Under direct ultrasound guidance, using [22-25]g needle, fine needle aspirations were performed of [size][left/right][sup/mid/inf] thyroid nodule. [Multiple] samples were obtained and adequacy of samples was confirmed by pathologist during the procedure.  No immediate complication.

 

IMPRESSION: Technically successful percutaneous FNA of [].  [Patient to follow-up with ordering provider][Please see CHCS] for final pathology results.

TESTICULAR

 

COMPARISON: []

 

FINDINGS: The right testis measures []x[]x[]cm and the left testis []x[]x[]cm.  Bilateral testis are normal in echotexture without focal intra-testicular mass. The right epididymal head measures []x[]cm and left epididymal measures []x[]cm.  No epididymal head cyst or spermatocele.  No hydrocele or varicocele (despite valsalva) noted.  Arterial and venous flow is confirmed within bilateral testes using spectral waveform analysis.

IMPRESSION: No intra/extra-testicular mass.  

ANAL SPHINCTER

HISTORY: [fecal incontinence s/p episiotomy].

FINDINGS:  transverse gray scale endorectal imaging of the anal canal was performed.  There is intact homogenously hyperechoic external sphincter measuring []mm in thickness.  Also, intact homogenously hypoechoic internal anal sphincter measuring []mm in thickness.  No focal defect, fissure, or mass.

IMPRESSION: Normal internal and external anal sphincter.  

CAROTIDS

COMPARISON: []

FINDINGS: gray scale, color, and spectral doppler analysis of bilateral common and internal carotid arteries was performed using linear transducer. Peak systolic velocities in cm/s are reported.

RIGHT CAROTID:

Right CCA [range]

Right proximal ICA[], mid ICA [], distal ICA []

Right ICA /CCA ratio []

LEFT CAROTID:

Left CCA [range]

Left proximal ICA[], mid ICA [], distal ICA []

Left ICA /CCA ratio []

[Mild/mod] carotid bulb atherosclerotic plaque.  Bilateral ECA are patent.  Bilateral vertebral arteries demonstrate antegrade flow.

IMPRESSION:

No hemodynamically significant flow-limiting stenosis of bilateral ICA.

 

[Mild/mod] atherosclerotic plaque.

 

Antegrade flow within bilateral vertebral arteries.

 

LOWER DVT

 

COMPARISON: []

 

FINDINGS: Grayscale and color doppler imaging of the [right/left] lower extremity was performed from the common femoral vein through popliteal vein at the confluence of the deep veins of the calf, with and without compression. Images show complete compressibility of the deep veins and no evidence of thrombus. Spectral waveforms of common femoral and popliteal veins show normal respiratory variation/phasicity, and response to augmentation. Other than at their confluence with the popliteal vein, the tibial veins and peroneal veins of the calf were not specifically interrogated. Visualized portion of the profunda vein shows no evidence of thrombus.

 

Limited evaluation of the contralateral [left/right] common femoral vein reveals normal respiratory variation/phasicity and response to augmentation.

 

IMPRESSION:  No evidence of [right/left] lower extremity DVT.

 

UPPER DVT

 

COMPARISON: []

 

FINDINGS: Grayscale and color doppler imaging of the [right/left] upper extremity was performed with and without compression. Images show complete compressibility of the deep veins (brachial, axillary, and internal jugular) and superficial veins (cephalic, basilica) with no evidence of thrombus.  Spectral waveforms of the subclavian and internal jugular veins show normal respiratory variation/phasicity and cardiac pulsatility. Brachiocephalic vein and SVC cannot be interrogated.

 

IMPRESSION:  No evidence of [right/left] upper extremity DVT.

 

VIABILITY

 

HISTORY:  [symptoms].  bHCG [level].

 

FINDINGS:  There is a single double-decidual gestational sac within [uterine fundus].  Yolk sac is normal and measures []mm. [Embryonic pole is seen within the amnion].  Mean gestation sac diameter of []mm which corresponds to estimated gestational age of  []wks []days  +/-  []days.   The crown rump length is []mm, which correlates to estimated gestational age of  []wks []days  +/-  []days.  [No embryonic cardiac activity at this time].  Embryonic cardiac activity at []bpm.  No perigestational hemorrhage is seen.  Cervix is closed.

 

Right ovary measures []x[]x[]cm and the left ovary is []x[]x[]cm.  [Normal ovarian arterial and venous flow waveforms.]  No adnexal mass or free fluid.  

 

IMPRESSION:

 

[Early] single living intrauterine pregnancy at []wks []days +/- []days by [G-sac/CRL] measurement . 

Lack of detectable [embryo/FCA] at this time is most likely due to [early pregnancy for which short-term follow-up ultrasound is recommended to establish viable pregnancy].   

 

Ultrasound dates are [dis/concordant] with clinical dates based on LMP which predicts age of []wks []days. [Patient is unsure of LMP].

 

[Size] subchorionic hemorrhage.

 

DATING u/s

 

HISTORY:  LMP [date] predicting []wks[]days with EDD of [date]

 

COMPARISON: []

 

FINDINGS:  Images show single, well formed intrauterine gestational sac containing a living [fetus/embryo <9wks]. Yolk sac measures []mm. The crown rump length is []mm, which correlates to estimated gestational age of  []wks []days  +/-  []days.  [Fetal/ embryonic] cardiac activity at []bpm.  The placenta is forming  [anteriorly/posteriorly].  No perigestational hemorrhage is seen.  Cervix is closed.  Right ovary measures []x[]x[]cm and the left ovary is []x[]x[]cm.  No adnexal free fluid.

 

IMPRESSION:

 

Single living intrauterine fetus with estimated gestational age of []wks[]days +/- []days based on crown rump length. This is [dis/concordant] with clinical dates based on LMP which predicts age of []wks []days.

 

Normal bilateral ovaries and adnexa.

 

 

 

If there is discordance (see chart below) and state the EDD based on CRL of today’s exam is [].  For redating, if expected GA is (column one) and the ultrasound age is off by (column 2), then they are discordant and re-date

GA                                                     RE-DATE IF

<7 weeks                                         >/=5 days off

8-12 weeks                                     >/=7 days off

12-18 weeks                                   >/=10 days off

18-30 weeks                                   >/=14 days off

>30 weeks                                       >/=21 days off

 

ANATOMY u/s

HISTORY:  (Include the EDD and what it is based on, if available – eg. LMP, concordant/discordant 1st trimester US etc).

 

COMPARISON: [1st trimester u/s] 

 

FINDINGS:  A single living intrauterine fetus is present in [] position. The cervix is []cm in length and closed.  The placenta is [], and normal in appearance. Cervix to placenta distance is [].  There is no previa.  Fetal cardiac activity is documented at []bpm.  Amniotic fluid level is subjectively normal .

 

BIOMETRY:  Biparietal diameter  (BPD) is []cm which corresponds to []w []d, head circumference is []cm which corresponds to []w []d, abdominal circumference is []cm which corresponds to []w []d, and femoral length is []cm which corresponds to []w []d.  Composite ultrasound estimated gestational age is []w []d +/- []w []d.   [Head to abdominal circumference ratio is normal.] Estimated fetal weight of []g +/- []g which is []th percentile per Hadlock.            

                                           

                                           Measurement (cm)                         Gestational age

Head circumference (HC):                                                         []                                       

Bi-parietal diameter (BPD):                                                     []                                        

Abdominal circumference (AC):                                             []                                         

Femur length (FL):                                                                    []                            

                                                                         Ratio                                  Normal range

HC/AC:                                                             []                                                       []-[]

FL/AC:                                                             []                                                        []-[]

FL/BPD:                                                          []                                                        []-[]

Average ultrasound age:                                                                                      [] wks []days +/- []

Expected age based on LMP of:                                                                          [] wks []days

Expected age based on dating ultrasound:                                                       [] wks []days

Estimated fetal weight (Hadlock):  []g +/- []g 

Estimated fetal weight percentile:  []th %ile

 

ANATOMY: Supratentorial brain (ventricles, choroid, cavum septum pellucidum), infratentorial brain  (cerebellum, posterior fossa), nuchal skin fold thickness,  nose and lips, heart (four chamber view, LVOT, RVOT), stomach, kidneys, bladder, 3 vessel cord, cord insertion, spine in long and transverse planes, and extremities were evaluated and is normal.

 

Inadequate visualization/evaluation of fetal [anatomy] secondary to fetal position.

 

IMPRESSION:

 

Single, live intrauterine pregnancy in [position] at []wks []days gestational age based on EDD of [date], as previously established by [LMP or first trimester ultrasound or clinical history].  Ultrasound today shows [appropriate interval] growth with estimated ultrasound age at  []wks []days +/- []days.  Fetal weight at []th percentile by Hadlock.

 

Fetal anatomy is adequately visualized and is normal.

 

Incomplete fetal anatomy evaluation due to [maternal body habitus and fetal positioning].  We will recall patient for additional imaging of [].

 

ADDITIONAL ANATOMY

 

HISTORY: []

 

COMPARISON: [anatomy scan]

 

FINDINGS/IMPRESSION: Supplemental imaging was performed as an adjunct to previously incomplete fetal anatomic survey on second trimester ultrasound dated [].  [anatomy] was adequately visualized and is normal.  In conjunction with prior anatomy ultrasound, this completes [normal] fetal anatomic survey. 

 

GROWTH u/s

 

HISTORY:  [clinical indication]. EDD of [date].

 

COMPARISON:  [anatomy scan]

 

FINDINGS:  A single living intrauterine fetus is present in [] position. The cervix is []cm in length and closed.  The placenta is [], and normal in appearance. Cervix to placenta distance is [].  There is no previa.  Fetal cardiac activity is documented at []bpm.  Amniotic fluid level is []cm which is between []-[]th %ile for gestation age.

 

BIOMETRY:  Biparietal diameter  (BPD) is []cm which corresponds to []w []d, head circumference is []cm which corresponds to []w []d, abdominal circumference is []cm which corresponds to []w []d, and femoral length is []cm which corresponds to []w []d.  Composite ultrasound estimated gestational age is []w []d +/- []w []d.   [Head to abdominal circumference ratio is normal.] Estimated fetal weight of []g +/- []g which is []th percentile per Hadlock.                                         

 

                                                         Measurement (cm)                         Gestational age

Head circumference (HC):                                                         []                                       

Bi-parietal diameter (BPD):                                                     []                                        

Abdominal circumference (AC):                                             []                                         

Femur length (FL):                                                                    []                            

                                                                         Ratio                                  Normal range

HC/AC:                                                             []                                                       []-[]

FL/AC:                                                             []                                                        []-[]

FL/BPD:                                                          []                                                        []-[]

              

Average ultrasound age:                                                                                      [] wks []days +/- []

Expected age based on LMP of:                                                                          [] wks []days

Expected age based on dating ultrasound:                                                       [] wks []days

Estimated fetal weight (Hadlock):  []g +/- []g 

Estimated fetal weight percentile:  []th %ile

 

IMPRESSION:

 

Single, live intrauterine pregnancy in [position] at []wks []days gestational age based on EDD of [date], as previously established by [LMP or first trimester ultrasound or clinical history].  Ultrasound today shows [appropriate interval] growth with estimated ultrasound age at []wks []days +/- []days. 

 

Fetal weight at []th percentile by Hadlock.

 

AFI is between []-[]th percentile for gestation age.

 

Peds abdomen

 

FINDINGS:

 

Pyloric stenosis=Real time ultrasound imaging of gastric pylorus shows [no focal stenosis or spasm]  [abnormal hypertrophy and resultant stenosis of pyloric channel with pyloric channel length >17mm and pyloric muscle thickness >3mm].  [No pyloric relaxation or peristalsis to suggest transient pylorospasm].

 

Intussusception=Real time ultrasound survey of abdomen demonstrates no specific findings of intussusception.  There is focal target sign appearance of bowel within [quadrant] with concentric ecogenic and hypoechoic rings consistent with intussusception.  

 

Appendicitis=Real time limited ultrasound survey of right lower quadrant in region of patient’s pain [fails to detect the appendix] [shows a dilated non-compressible blind-ending tubular structure with hyperemia consistent with inflamed appendix].  No focal free fluid or abscess.  IMPRESSION: Appendix not visualized on ultrasound therefore equivocal for appendicitis, consider low dose CT scan.

 

Hip ultrasound

 

FINDINGS: Real-time transverse and coronal dynamic bilateral hip ultrasound was performed in [flexed] position.  There is good coverage of bilateral femoral heads by acetabuli.  Alpha angle is [≥60deg] on the left and [≥60deg] on the right. No hip dislocation or subluxation despite stress maneuvers.  [Mild physiologic laxity].  [No pulvinar noted interposed between femoral head and acetabulum].  No hip effusion.

 

IMPRESSION: Normal bilateral hip ultrasound.

 

Neonatal head ultrasound

 

FINDINGS: Neonatal head ultrasound was performed in sagittal and coronal projections via anterior fontanelle.  Ventricles and sulci are unremarkable.  No subependymal (grade I-IV germinal matrix at caudothalamic groove), intraventricular, or intracerebral hemorrhage.  No hydrocephalus or periventricular leukomalacia (PVL).  Echotexture of brain parenchyma especially periventricular white matter is normal.  [Prominent subarchanoid spaces ≤4mm measured in coronal view at level of foramen of Monroe; interhemispheric fissure ≤6mm].  No congenital anomalies.

 

IMPRESSION: Normal neonatal head ultrasound.

 

Neonatal spine ultrasound

 

FINDINGS: Real time ultrasound examination of neonatal lumbosacral spine in longitudinal and transverse planes with baby in prone position.  Spine is visualized from [L1] through [sacrum].  Distal spinal cord and nerve roots are normal in appearance and freely mobile.  Conus medullaris terminates [normally at or above L2-3 disk space] and is normal in appearance without evidence for tethering.  Thecal sac terminates at [S2] with filum terminale measuring [<2mm in thickness.  No abnormal cyst/mass, meningocele, lipoma, or sinus tract.  Visualized osseous structures are normal without spinal dysraphism.  No abnormal skin lesion (sacrococcygeal dimple, hair patch, or hamngioma)  is noted on physical exam.

 

IMPRESSION: Unremarkable examination of lumbosacral spine without evidence for spina bifida or tethered cord.

 

Liver Transplant

HISTORY: []

COMPARISON: []

FINDINGS: gray scale, color, and spectral doppler ultrasound examination of transplant liver was performed.

Liver Parenchyma
Echogenicity: [normal][increased]
Focal lesions: []
Fluid collections: []
Bile ducts: []

Hepatic Vasculature
Portal vein waveforms and direction of flow: []
Portal vein velocities:     main [], right [], left []
Hepatic vein waveforms: [normal] [dampened]
Hepatic vein velocities: right [], middle[], left[]
Hepatic artery velocities and resistive indices: main[], right[], left[]

Misc
Inferior Vena Cava: [patent]
Splenic Vein velocity: []
Intraabdominal free fluid: []
Other: []

IMPRESSION: Normal hepatic transplant without complication.
 
Renal Transplant

HISTORY: []

COMPARISON: []

FINDINGS: gray scale, color, and spectral doppler ultrasound examination of [right/left] lower quadrant transplant kidney was performed.

FINDINGS:

Transplant Kidney
Echogenicity: []
Focal lesions: []
Hydronephrosis: [present][absent]
Peritransplant fluid: []

Vasculature
Intrarenal arterial waveforms: [normal]              

Resistive indices: []
Main renal and iliac vessels: [patent]                    

Bladder

[distended][contracted]

Other

[]

IMPRESSION: Normal renal transplant without complication.

 


   .
   .
   .