Medal Study No.
MEDAL STUDY
ULTRASOUND REPORT
Patient Initials
(Form 04)
Part A
Name of clinician who completed ultrasound
Please tick appropriate box:
Date of USS:
D
Senior sonographer...............................................................
Junior sonographer...............................................................
Consultant radiologist...........................................................
Trainee radiologist................................................................
Consultant gynaecologist......................................................
Trainee gynaecologist............................................................
Other, please state................................................................
M M
D
Y
Y
M
Y
Y
......training grade
..... training grade
Note:
USS Start Time =time transducer placed on patient
USS Time started: H H
H
: M M
USS Time finished: H H
H
H
Are you menstrauting?
No
: M M
USS Finish Time = time final image obtained
H
Yes
If ‘yes’ Date of last menstrual period
Part B
Transabdominal Scan (TA) (full bladder)
D
M M
D
M
Y
Date TA Scan completed:
UTERUS Present:
Y
Y
D
Y
D
M
No
M
M
Y
Y
Y
Y
Yes
UTERUS Dimensions:
Cervico-fundal length
.
cm
Anterior Posterior length
.
cm (at thickest part of corpus)
Transverse
.
cm
Transabdominal Scan (TA) - Not performed
Part C
Transvaginal Scan (TV) (empty bladder)
UTERUS Present:
No
Date TV Scan completed:
D
M
D
M
M
Y
Y
Y
Y
Yes
.
Dimensions (longitudinal/sagittal plane) Length
cm, width
.
cm, Transverse
.
cm
If not available from abdominal scan
Position:
Anteverted
Retroverted
Axial
Myometrial appearance:
Thickened
No
Yes
Striated
No
Yes
Uterine Tenderness
No
Yes
Restricted mobility
No
Yes
Endometrium (double layer)
………………………… mm (At thickness part of Corpus)
Transvaginal Scan (TV) - Not performed
Ultrasound Report (Form 04)
Page 1 of 3
Version 1.4 – 08th November 2012
OVARY
Present
Location
Length
(cm)
Ovary
LEFT
No
Width
(cm)
Transverse
(cm)
Cysts present
No
Abutting Uterus
Yes
Volume
(ml)
Pelvic side wall
Yes
If yes, size of largest
Other (describe)
…………………… mm
…………………………………
RIGHT
No
Abutting Uterus
Yes
Pelvic side wall
No
Yes
If yes, size of largest
Other (describe)
…………………… mm
…………………………………
Part D – Free fluid (if applicable)
Free fluid present
If yes, amount
No
Yes
Moderate
Large
No
Yes
Pouch of Douglas
No
Yes
Left Adnexa
No
Yes
Right Adnexa
No
Yes
Small
Loculated fluid present
If yes, location
Elsewhere, please state where
…………………………....
Organ specific tenderness
No
Yes
If yes, location
Left ovary
No
Yes
Right ovary
No
Yes
Uterus
No
Yes
Elsewhere, please state where
If yes, amount
Small
Site specific tenderness
If yes, location
…………………………....
Moderate
Large
No
Yes
Pouch of Douglas
No
Yes
Left Adnexa
No
Yes
Right Adnexa
No
Yes
Elsewhere, please state where
Organ mobility restricted
…………………………....
No
Yes
If yes, which organs…………………………………………….....................................................................................
Ultrasound Report (Form 04)
Page 2 of 3
Version 1.4 – 08th November 2012
Part E – Bladder ultrasound
D
Date Bladder ultrasound completed:
D
M
M
M
Y
Y
Y
Y
Transvaginal scan of bladder (empty bladder)
Post void residual volume
.
ml,(= height
.
mm x width
.
mm x
.
mm depth x 0.7 ml)
Bladder ultrasound not performed……………………………………………….
Bladder wall thickness
Trigone (perpendicular to lumen at thickest part of trigone) .……… mm
Dome midline
.……… mm
Anterior wall, midline
………. mm
Bladder wall thickness not performed………………………………………….
Form completed by:
(if different to person who completed procedure):
PRINT NAME: ..................................................................
Date: D
Ultrasound Report (Form 04)
Page 3 of 3
D
M
M M
Y
Y
Y
Y
Version 1.4 – 08th November 2012