3.1 Guidelines for report writing
An ultrasound report may be defined as the recording and interpretation of observations from an ultrasound examination.
General Comments
- The ultrasound report should be written and issued by the sonographer undertaking the ultrasound examination and viewed as an integral part of the whole examination
- The report should be written as soon as possible after the examination has been completed
- The name and status of the sonographer issuing the report should be recorded on the report
- The sonographer should take responsibility for the accuracy of the report and ensure that the report is communicated to the appropriate personnel
- The sonographer should be aware of his/her limitations and consequently seek clinical advice when necessary.
Report Style
- The style of the report should be concise, clear and easily understood
- Standard reports which are understood and accepted by staff within a hospital may need to be modified for outside referrals
- Potentially ambiguous phraseology should not be used
- Short paragraphs should be used and the burying of important comments avoided
- Abnormal and related findings should be grouped
- Irrelevant information should be avoided
- Technical findings should be described
For example:
- There is a simple right adnexal cyst present measuring 7.6cm maximum diameter, arising from the right ovary
- A well defined mass with mixed echoes is present in the left rectus sheath. The lesion is exquisitely tender The mass measures 5.2 x 4.6 x 3.6cm
- Acoustic or technical language should be used when it significantly assists in the diagnosis. ‘Echogenic’ is, for example, frequently used inappropriately to indicate increased reflectivity. It should be avoided unless qualified by a comparative such as ‘increased echogenicity’
- Abbreviations should only be used when the user is confident that they will be clearly interpreted
- The content of the examination and the technique(s) used should be documented
For example:
- A large left sided varicocoele is present and, in view of this, the kidneys were examined
- The placental edge could not be identified trans-abdominally and a vaginal scan was undertaken
Action taken should be reported
For example:
- I have informed the patient that she has an ovarian cyst and that a follow up scan is arranged in six weeks time
- In view of the findings I have personally discussed these results with Dr ***** by telephone
A succinct conclusion should be included at the beginning or the end of the report
Clinical Content
The report should address the clinical question and generally pertain to the reason for referral.
For example:
- The gallbladder is very tender and cholecystitis is the likely cause of the right upper quadrant pain
- The scan confirms the clinical impression of oligohydramnios. There is significant fetal bladder dilatation and bilateral hydronephrosis in keeping with bladder outflow obstruction
The report should be conclusive where possible, indicating when the appearances are consistent with a specific diagnosis. Where no conclusion is possible alternative explanations for the ultrasound appearances may be offered.
The report should guide the referring clinician in further management.
For example:
- Although a distal bile duct calculus has not been demonstrated the appearances are in keeping with a distal biliary obstruction and further investigation is advised to evaluate the cause of the jaundice
- There is evidence of a significant ventricular septal defect and a detailed assessment of the cardiac anatomy is advised
Any limitations should be stated and, if a relevant organ has not been fully examined, the reason(s) should be indicated.
For example:
- pancreas obscured by bowel gas
- gall bladder is contracted, patient not fasted
The presence/absence of ascites, lymphadenopathy or distant metastases should be noted in cases of known primary carcinomas.
It may be appropriate, depending on local practice, to suggest further investigations which may clarify the diagnosis. These include other imaging modalities such as a plain X-ray, CT, MRI or invasive procedures.
For example:
“There is a poorly defined 7 cm, mainly solid mass adjacent to, and separate from, the left kidney. This may be bowel or a lymph node mass. Suggest CT or MRI to clarify”
The exclusion value and significance of the ultrasound appearances should be stated where relevant.
The sonographer should be aware at all times of the implications for the patient of the contents of the report and act in accordance with local guidelines.
Report Proforma/Worksheet
- Where a report proforma is used e.g. in obstetric • reporting, it should include a clear definition of what a positive, negative or missing response means. It is essential to ensure that the precise meaning of statements made on the proforma is clearly understood. It is recommended that a free-text facility is available on the report form and is used when appropriate
- The use of worksheets, when used in conjunction with departmental schemes of work, is useful as an aide memoir for training purposes
(Examples of obstetric ultrasound worksheets can be found in the Appendix)
Guidance for Completing Patient Notes / Hospital Records
- A provisional report written in the patient notes should always be written in black ink. If handwriting is illegible, the report should be printed. The report must be written in an appropriate part of the notes, dated, signed and the reporter’s name and status printed
- Abbreviations should be avoided and words always written in full for example DVT should be written as deep vein thrombosis or SFV, superficial femoral vein, as it cannot be assumed that the person reading the report will be familiar with the writer’s abbreviations
- Correction fluid or sticky labels should not be used to cover errors. Any error that is made should have a single horizontal line through the words or sentence and initialed. If the wrong patient’s report is entered in the notes then the whole report should be removed by a single horizontal line scored through for each line of text and signed with a note of explanation e.g. written in error
- If additional details are to be included, it is advised that a case note continuation sheet is used and a patient label put on the addressograph area. If a patient label is not available the patient’s hospital number, full name, address and date of birth should be entered clearly
- The provisional report should be followed up by a printed verified report as soon as possible. If a second opinion has been sought for the examination or report, the person giving the opinion should also be noted in the report and their status given
Examples of Examination specific reporting
Listed in this section are common examples of suitable report formats for use with various specific referrals.
These are not intended to be comprehensive or prescriptive.
3.2 Breast Ultrasound
The report should include the following information:
- clinical indication for examination
- breast under examination
- location within breast of area(s) examined
- differential diagnoses in order of likelihood
- recommendations for further imaging and/or investigations
The report should describe any pathology in terms of:
- clinical and/or mammographic correlation
- radial location using standard ‘clock face’ annotation and distance from nipple
- lesion size and extent including the greatest diameter and/or tumour volume
- margin definition
- internal echo-texture
- posterior through-transmission characteristics
- vascularity
- appearances of adjacent structures
It must be remembered that breast ultrasound is not appropriate as a screening investigation for cancer and has a limited ability to demonstrate morphological changes associated with in-situ disease. The terms ‘no abnormality detected’ and ‘no anatomical disturbance’ are therefore recommended when no pathology has been demonstrated.
Abnormal Ultrasound Appearances
Referral for Palpable Mass Left Breast
The palpable lump at the 12 o’clock 30mm position is a 24mm well-defined anechoic mass showing posterior acoustic enhancement/increased through transmission.
Appearances are those of a simple cyst.
Referral for Examination of Right Breast and Axilla:
The palpable lump at the 4 o’clock 30mm position is a 14mm irregular ill-defined solid mass showing posterior acoustic shadowing. The internal arterial vessels show high resistance high velocity flow.The axillary lymph nodes are enlarged, round and uniformly hypoechoic.
Appearances are those of malignancy with LN involvement.
Needle core biopsy required for confirmation.
Referral for Examination of Left Breast:
The mammographically detected lesion in the UOQ is a 12mm well defined solid mass with posterior acoustic enhancement and edge shadowing.
Internal arterial vessels show low resistance low velocity flow.
Appearances are those of a fibroadenoma.
Histological confirmation is suggested.
(There is a wide spectrum of diffuse proliferative benign disease which may be described variously as benign breast change (BBC), benign breast disease (BBD), fibrocystic change (FCC) or fibrocystic disease (FCD).)
3.3 General Medical Ultrasound
It may be useful to have a standardised reporting format for normal abdominal scans which includes all the organs routinely examined and which is acceptable to the imaging department and referring clinicians.
Several formats may be required according to the reason for referral in order to answer the relevant clinical question(s).
An example of a simple to read ‘factual’ abdominal ultrasound report is given below:
Technique: Patient fasted. Transabdominal.
Findings: Liver: Nodular appearance consistent with cirrhosis. No focal lesion. Portal vein patent with forward flow. Spleen: Enlarged - 17cm (Normal <12cm). Gallbladder: Normal. Common Bile Duct: Normal - 5mm.Kidneys: 5cm simple cyst upper pole right kidney. Otherwise normal. Right 11.2cm. Left: 10.5cm.
Aorta: Normal.
Other Findings: Abdominal wall varices.
Comment: Findings are consistent with cirrhosis and portal hypertension with a patent portal vein and abdominal wall varices.
Referral for suspected biliary disease
Normal ultrasound appearances of the liver. The gallbladder is clear. No evidence of biliary duct dilatation.
The pancreas, spleen, both kidneys and aorta are normal.
Referral for urological symptoms
Normal ultrasound appearances of both kidneys, bladder and prostate. No ultrasound evidence of renal calculi, mass or obstruction.
Normal ultrasound appearances of both kidneys and bladder. Pre-micturition volume ... mls.
Post micturition volume ... mls.
Referral for known primary carcinoma
Normal ultrasound appearances of liver, gallbladder, CBD, pancreas, spleen, both kidneys and adrenal glands. No evidence of abdominal lymphadenopathy or ascites.
Referral for palpable RUQ mass
Normal ultrasound appearances of liver, gall bladder, CBD, pancreas, spleen and both kidneys. Prominent Reidel’s lobe noted. No RUQ mass identified.
Referral for fatty intolerance
The gall bladder contains several calculi. Normal common duct with no intra-hepatic duct dilatation. The ultrasound appearances of the liver, pancreas, spleen, both kidneys and aorta are normal.
Referral for RUQ pain
The liver has increased echogenicity with reduced prominence of portal tracts an appearance consistent with fatty change.
There is a 3 cm highly reflective focal lesion in segment 6 of the liver. The appearances are typical of an haemangioma but if there is clinical suspicion of malignancy then metastasis cannot be excluded. Normal appearances of the gall bladder, pancreas, spleen, both kidneys and aorta.
Referral for bleeding varices
Shrunken nodular liver. Enlarged spleen (16 cm) with varices around the hilum.
Reverse flow is present in the portal vein and there is increased intra hepatic arterial flow. Patent right and middle hepatic veins - left technically difficult to demonstrate.
Patent paraumbilical vein is noted. Gross ascites is present.
Conclusion: ultrasound appearances are compatible with advanced liver disease with portal hypertension.
Referral for Contrast Enhanced Ultrasound
The sonographer should ensure that the report describes: -
- the behaviour of the lesion(s) in the arterial, portal and late phases
- if the behaviour is benign or malignant and if possible conclude with the nature of the lesion e.g. haemangiom
- cases where characterisation of small lesions (<1cm) are difficult or larger lesions which are atypical are referred for other imaging investigations
- technically sub-optimal examinations when a referral for further imaging is desirable
3.4 Gynaecological Ultrasound
The report should contain the following information:
- examination method, i.e. vaginal and/or abdominal
- named person as chaperone if present
- date of the last menstrual period (LMP)
- length of menstrual cycle
Several standard report formats may be required according to the reason for referral in order to answer the relevant clinical question(s):
- pathological findings
- organ of origin
- location
- size
- internal reflectivity - cystic, solid, complex, septated, solid foci
- posterior through transmission
- borders - definition
- other associated appearances e.g. ascites
Referral for pelvic pain
Vaginal scan with patient consent.
Day 23 of 29-31 regular cycle.
Anteverted uterus - normal in size and echo pattern with a 5mm cystic structure in the cervical canal.
Ultrasound appearances are consistent with a Nabothian cyst.
Endometrial thickness Xmm with some fluid noted in endometrial cavity.
Ultrasound appearances of both ovaries are normal for luteal phase of cycle.
No pelvic mass or fluid demonstrated.
Referral for subfertility investigation
Vaginal scan with patient consent.
Day 18 of 28 day cycle. Clomid 50mg days 2-6.
Retroverted uterus with thickened (Xmm) endometrium.
Ultrasound appearances of both ovaries are normal. 25mm corpus luteal cyst in the right ovary.
No other adnexal masses seen. No fluid in the Pouch of Douglas.
Ultrasound appearances are compatible with the luteal phase.
Referral for post menopausal bleeding
Transabdominal scan.
Approx. 3 years post menopause.
Ultrasound appearances are of a normal anteverted uterus with thin (Xmm) endometrium and right ovarian volume of Ymls.
Left ovary was obscured by bowel gas.
No adnexal masses evident although left side difficult to visualise. No fluid in the Pouch of Douglas.
Referral for menorrhagia
Vaginal scan with patient consent.
25 days post LMP. Irregular cycle 4-6 weeks.
Retroverted uterus containing several submucosal fibroids on the anterior wall, the largest of which is Xmm in diameter. Ultrasound appearances of both ovaries are normal with a corpus luteum in the left ovary.
Referral for deep dyspareunia
Patient declined a vaginal scan.
LMP - unsure ?six weeks ago. Irregular cycle.
Anteverted uterus with endometrial thickness Xmm.
Ultrasound appearances of the left adnexa are normal but left ovary not demonstrated - ?absent (patient unsure of this when questioned.)
The right ovary demonstrates normal ultrasound appearances. Adjacent to this ovary is a complex structure measuring YxYxYmm containing low level echoes.
Small amount of fluid noted in the Pouch of Douglas.
These ultrasound appearances are consistent with pyosalpinx, tubo-ovarian abscess or ectopic pregnancy.
Referral for suspected pelvic mass
Transabdominal scan.
Patient says she has had a partial abdominal hysterectomy in December, 1986.
There is an irregular complex mass arising out of the pelvis measuring 15 cm in diameter.
It contains several solid highly vascular areas. Ovaries not demonstrated.
The ultrasound appearances of the liver are normal but there is bilateral hydronephrosis and ascites is present. These ultrasound appearances are consistent with ovarian malignancy. In view of these findings a CT examination may be helpful for staging purposes.
Referral for Hy-Co-Sy examination:
Examination carried out according to departmental guidelines.
Day 6 of 30 day cycle.
Transabdominal and vaginal scans carried out prior to the procedure.
Anteverted uterus with a thin endometrium consistent with early proliferative phase of the cycle.
Both ovaries demonstrated.
No abnormal pelvic ultrasound appearances.
Ultrasound contrast media introduced into uterine cavity. Ultrasound appearances of the cavity are normal. Both Fallopian tubes patent. No filling defect demonstrated.
Normal ultrasound appearances.
Examination carried out according to departmental guidelines.
Day 14 of 28 day irregular cycle.
Transabdominal and vaginal scans carried out prior to the procedure.
Uterus is normal in size, shape and texture.
Endometrium measures ….mms, preliminary in appearance. Endometrial measurements where A …mm; C…..mm:
E…..mm.
Rt ovary (state the 3 dimensions); Lt ovary (state 3 dimensions) it contains a dominant follicle of …cm in diameter.
Hycosy - Xmls of contrast agent used. Spontaneous flow demonstrated, with spill over both ovaries.
Bilateral tubal patency.
3.5 Musculo-Skeletal Ultrasound
Shoulder
Clinical History: Left shoulder pain ?cuff tendonitis.
There is a minor focus of tendonitis in the supraspinatus tendon but no tear. No significant bursal thickening. Normal long head of biceps, subscapularis and infraspinatus tendons. Normal AC joint.
Achilles Tendon
Clinical History: Pain right Achilles tendon.
The right Achilles tendon was mildly thickened and hypoechoic approximately 5 cms from its calcaneal insertion which may represent a focal tendinosis. Normal calcaneal insertion. No evidence of tear.
3.6 Obstetric Ultrasound
First Trimester - Early Pregnancy
• Pregnancy of unknown location 1
Transabdominal scan, EVS declined.
Single gestation sac present within the uterus.
Gestation sac volume 0.4mls, equivalent to 5+ weeks.
No embryo or yolk sac seen.
Normal appearances with measurements in agreement with recent positive pregnancy test.
Appointment made to rescan in 10 days to assess presence of embryo, heart pulsations and therefore an ongoing pregnancy.
• Pregnancy of unknown location 2
Vaginal scan carried out with consent. Chaperone present.
Pregnancy test positive 8 days ago.
Anteverted uterus with thickened endometrium. No gestation sac identified.
Normal ovaries. Corpus luteum noted on left ovary.
No adnexal mass see. No free fluid present.
The ultrasound findings in isolation do not indicate an ectopic pregnancy. However, in view of the clinical symptoms of mild right sided pain and vaginal spotting, further management is recommended e.g. serum hCG monitoring.
• Pregnancy of uncertain outcome
Vaginal scan carried out with consent. Chaperone present as requested.
Ms X reports a positive pregnancy test 6 weeks ago with some recent vaginal spotting.
Mean gestation sac diameter 12mm = 5+ weeks. No embryo or heart pulsations seen as yet.
Ms X is aware of the discrepancy between her menstrual history and today’s ultrasound findings.
We have arranged to rescan one week to review the findings and exclude a missed miscarriage.
• Missed miscarriage 1
Vaginal scan carried out with consent. Chaperone present.
Mean gestation sac diameter 40mm, equivalent to 9+ week size.
The gestation sac was empty, with no evidence of an embryo or yolk sac seen.
The findings of an ongoing pregnancy of this gestational age would include a live embryo, 22-30mm in length and yolk sac. These were not present.
Conclusion: appearances indicate a missed miscarriage.
• Missed miscarriage 2
Vaginal scan carried out with consent. Chaperone declined.
Irregularly shaped gestation sac present within the uterus.
10mm embryo seen (equivalent to 7+ weeks) but no heart pulsations were demonstrated.
I have discussed these findings with Ms X and referred her to the gynae on-call team.
Conclusion: appearances indicate a missed miscarriage.
• Ectopic pregnancy
Vaginal scan carried out with consent. Chaperone present.
6 weeks since LMP.
Anteverted uterus with thickened (25mm) endometrium.
There is a complex mass in the right adnexae, mean diameter 30mm.
Normal left ovary and adnexa. Fluid in the Pouch of Douglas.
Conclusion: these appearances are highly suggestive of an ectopic pregnancy.
Gynaecology team on-call contacted - to return to Casualty for review by Dr X.
First Trimester - Dating
• Singleton pregnancy, 1st trimester dating
Vaginal scan carried out with consent. Chaperone declined.
Intrauterine pregnancy
Single live embryo. CRL = 18mm
Gestational age = 8 weeks + 3 days. USEDD = XX.YY.ZZZZ
Combined 1st trimester serum and nuchal translucency screening for Down’s syndrome has already been discussed at booking and Ms X wishes to have this carried out. She is aware that the optimal time for her PAPP-A blood test to be taken is at 10 weeks and we have made this appointment for her. We have also made her nuchal translucency screening appointment for 4 weeks time.
• Singleton pregnancy, 1st trimester dating, Down’s screening declined
Transabdominal scan carried out
Single live fetus. CRL = 60mm
Gestational age = 12 weeks + 4 days. USEDD = XX.YY.ZZZZ
Ms X has declined Down’s screening therefore nuchal translucency assessment was not carried out.
She wishes to have a routine anomaly scan and this appointment has been made for her.
• DCDA twin pregnancy, 1st trimester dating
Vaginal scan carried out with consent. Chaperone declined.
A single posterior placenta together with the ‘lambda sign’ appearance of the intertwin membrane at the placental interface indicates a dichorionic diamniotic (DCDA) twin pregnancy.
Heart pulsations noted in both embryos.
Twin 1, the lower twin, is on the maternal left. Twin 2, the upper twin, is on the maternal right.
Twin 1 CRL = 16mm; Twin 2 CRL = 18mm
Gestational age, based on the measurement of the larger embryo = 8 weeks + 3 days
USEDD = XX.YY.ZZZZ
Down’s screening has already discussed at booking visit and Ms X wishes to have this carried out. An appointment for nuchal translucency screening at 12 weeks has therefore been given. She is aware that we are unable to offer nuchal translucency combined with serum screening in a twin pregnancy.
First Trimester - Nuchal Translucency Screening
• DCDA twin pregnancy, nuchal translucency - reduced risk
Transabdominal scan carried out.
Maternal age 37 years.
A single posterior placenta together with the ‘lambda sign’ appearance of the intertwin membrane at the placental interface confirm a dichorionic diamniotic (DCDA) twin pregnancy.
Twin 1, the lower twin, is on the maternal left. Twin 2, the upper twin, is on the maternal right.
Gestational age = 12 weeks and 5 days
Twin 1 CRL 60mm NT 1.7mm, Twin 2 CRL 64mm NT 1.5mm
Risk of Trisomy 21 based on maternal age = 1:242
Adjusted risk of Trisomy 21 for Twin 1 = 1:1066
Adjusted risk of Trisomy 21 for Twin 2 = 1:1298
Ms X is aware that the nuchal translucency measurements have resulted in a reduced risk for Down’s syndrome for both fetuses. The routine anomaly scan appointment has been arranged. We have also arranged for 4 weekly (monthly) scans from 24 weeks, to assess fetal growth as per our protocol.
• MCDA twin pregnancy, nuchal translucency - increased risk
Transabdominal scan carried out.
Maternal age 37 years.
A single posterior placenta together with the ‘T sign’ appearance of the intertwin membrane at the placental interface confirm a monochorionic diamniotic (MCDA) twin pregnancy.
Twin 1, the lower twin, is on the maternal left. Twin 2, the upper twin, is on the maternal right.
Gestational age = 12 weeks and 0 days.
Twin 1 CRL 56mm NT 1.5mm, Twin 2 CRL 56mm NT 3.5mm
Risk of Trisomy 21 based on maternal age = 1:100
Adjusted risk of Trisomy 21 for the pregnancy = 1:7
Ms X is aware that the nuchal translucency measurements have resulted in an increased risk for Down’s syndrome for the pregnancy. She is also aware that increased nuchal translucency has been reported as an early sign of TTTS. We have discussed briefly diagnostic testing and 2nd trimester ultrasound screening including detailed fetal cardiac assessment. Ms X understands that there is a miscarriage risk, in singleton pregnancies, of approximately 1%, associated with both CVS and amniocentesis. We have made an appointment for Ms X and her partner with our screening midwife later on today to discuss the scan findings and her management options.
Second Trimester
• Singleton pregnancy, 2nd trimester dating
Single live pregnancy.
HC = 130mm
AC = 105mm
FL = 22mm
Anterior placenta, not low.
Gestational age, based on dating parameters of HC and FL = 16 weeks and 4 days.
USEDD = XX.YY.ZZZZ
Ms X has already discussed screening for Down’s syndrome and wishes to have this done. She understands that the pregnancy is too advanced for combined serum and nuchal translucency screening.
We have completed her triple test serum screening form and sent her to have her blood taken today.
Routine anomaly scan booked for 4 weeks time.
• Routine anomaly screening, low placenta
The appearance of the fetal anatomy is normal.
The fetal growth velocity is normal.
Normal amniotic fluid volume.
The anterior placenta is low lying at present but does not extend across the internal os. No evidence of vasa praevia as assessed with colour Doppler. We have arranged to review placental site at 32 weeks as per protocol. Ms X is aware that vaginal imaging may be necessary at this examination.
• Completion of anomaly scan 1
Repeat examination at 22 weeks + 4 days due to initial poor visualisation at routine anomaly scan at 20 weeks + 4 days.
Normal situs.
Normal appearance of the four chamber view of the heart.
Outflow tracts and fetal face could not be adequately seen.
Ms X is aware that we have been unable to carry out a complete fetal anatomy survey and that this has been due to poor visualisation because of a BMI of 36.
In keeping with our guidelines we have not arranged any further scans to review the fetal anatomy but, as this is Ms X’ first pregnancy, we have arranged to rescan for growth at 32 and 36 weeks.
• Suspected spina bifida
Abnormal, ‘banana shaped’ cerebellum. Trans-cerebellar diameter 15mm.
Dilated ventricles noted, both atria 11mm.
Lower lumbar and upper sacral vertebrae and skin covering abnormal in appearance.
Conclusion: appearances indicate spina bifida (L3-S2) with meningocoele and hydrocephalus.
I have discussed these findings with Mr X who will see the parents later this morning. I have explained my findings to the parents.
• Mild renal pelvic dilatation
Mild dilation of both renal pelves noted.
AP diameter of left pelvis 6mm, right pelvis AP 7mm.
No other markers of abnormal karyotype were seen. I note the low risk Down’s screening result.
I have discussed these findings with Ms X.
Re-scan arranged at 32 weeks to monitor renal pelves.
Third Trimester
Fetal Growth
• Growth velocity within normal limits, singleton pregnancy.
BPD = 84mm HC = 310mm
AC = 260mm FL = 65mm
The fetal growth velocity is within normal limits, with the head and femur measurements on the 50th
centile and the abdominal circumference on the 10th centile.
Estimated fetal weight = Xgm.
Normal amniotic fluid volume, AFI 15.5 cm.
Ms X reports good fetal movements which were also observed during the examination.
We have arranged a further appointment in 2 weeks to assess fetal growth.
• Asymmetrical growth restriction, singleton pregnancy
BPD = 84mm HC = 310mm
AC = 260mm FL = 65mm
The head circumference lies on the 40th centile while that of the abdomen has fallen to below the 5th centile.
Estimated fetal weight = Xgm.
Normal umbilical artery Doppler trace with positive end diastolic flow. Middle cerebral artery PI below the 5th centile.
Reduced amniotic fluid volume, AFI 8.5cm.
Ms X reports a decrease in fetal movements over the last few days. Fetal movements were seen today during the examination but the fetus was quiescent for the majority of the examination.
These findings suggest asymmetrical intra-uterine growth restriction with redistribution. The obstetric team has been contacted - for review in ANC today. We will review the fetal growth in 2 weeks if undelivered.
• Placental Localisation, 36 Weeks
Cephalic presentation.
BPD = 89mm HC = 325mm
AC = 300mm FL = 69mm
Normal growth velocity. Estimated fetal weight = Xgm
Normal amniotic fluid volume, AFI = 15.0cm
Ms X reports good fetal movements that were also observed during the examination.
Vaginal scan carried out with Ms X’s consent. A chaperone was declined.
The leading edge of anterior placenta is 15mm from the internal os as assessed vaginally. There was no evidence of vasa praevia - no vessels were seen near to or crossing the internal os as assessed with colour Doppler.
We have made Ms X an ANC appointment with her consultant to discuss her further management.
3.7 Paediatric And Neonatal Ultrasound
Neonatal Cranial Ultrasound
Clinical history: 30 weeks premature, ?intracranial haemorrhage.
Normal intracranial appearances.
Normal ventricular size.
No evidence of haemorrhage demonstrated.
Neonatal Cranial Ultrasound.
Clinical history: 28 weeks premature, ?intracranial haemorrhage.
Peri-ventricular flaring demonstrated.
There is midline shift of the ventricular system due to an extensive area of haemorrhage inferior to the third ventricle and extending into the temporal cortex.
Colour Doppler demonstrates active flow within this area suggesting continuing enlargement of this area of haemorrhage.
Paediatric Hips
Normal ultrasonic appearance of both hips, which are in joint.
(Right hip angle is x degrees, Left hip angle is x degrees).
Paediatric Hips
Both hips are immature and the left hip is in a dislocated position.
Right hip alpha angle is xx degrees, beta angle x degrees, Graff classification x; Left hip alpha angle is xx degrees, beta angle x degrees, Graff classification x.
Renal Ultrasound
Referral for Recurrent Urinary Tract Infections.
Both kidneys are normal in size and structure. No evidence of mass or obstruction. The urinary bladder is clear and empties completely on micturition.
Renal Ultrasound
Referral for Recurrent Recurrent Urinary Tract Infections.
The right kidney is markedly hydronephrotic with significant cortical loss. No apparent ureteric distension.
Normal left kidney, no evidence of obstruction. The urinary bladder is clear and emptied on micturition.
The appearances of the right kidney are most probably due to a PUJ obstruction. A MAG3 Renogram is advised for confirmation.
Abdominal Ultrasound
Referral for palpable epigastric mass.
There is a large mass of mixed echogenicity in the epigastric region measuring 8.7 x 9.5 x 10cms.
This is possibly related to the left lobe of the liver but this was difficult to differentiate. The liver texture otherwise appears normal. Pancreas, spleen and kidneys are normal. No apparent abdominal lymphadenopathy. Differential diagnoses include hepatoblastoma, neuroblastoma and lymphoma.
Further investigation by CT and biopsy are required.
3.8 Superficial Ultrasound
Thyroid Ultrasound
Referral for ?goitre. Normal thyroid function tests.
The thyroid gland is normal in size and echogenicity. There are no discrete nodules evident.
No lower cervical lymphadenopathy.
Conclusion - normal examination.
Thyroid Ultrasound
Referral for ?retrosternal goitre.
This confirms a large diffuse goitre which is of altered echogenicity throughout. There are no discrete nodules.
There is evidence of retrosternal extension bilaterally, most prominent on the left side.
No lower cervical lymphadenopathy.
Parotid Ultrasound
Referral for swelling left parotid gland ?cause.
There is a well defined 1.5cm hypoechoic mass superficially in the tail of the left parotid gland. It contains a small central cystic area. This could represent a small pleomorphic adenoma or possibly a Warthin’s tumour. Normal submandibular salivary glands. No lower cervical lymphadenopathy.
Ultrasound guided FNA is advised.
Testicular Ultrasound
Referral for palpable mass.
There is a well defined 2.5cm mass of mixed echogenicity in the left testis. In view of the patient’s age this is most likely to be a teratoma. The right testis and epididymis are normal.
3.9 Vascular Ultrasound
Carotid Ultrasound
The report should indicate the presence of disease including location and extent.
Where significant disease is found i.e. >50% stenosis, the report must include:
- the peak systolic velocity PSV and end-diastolic velocity EDV in the distal CCA (i.e. 1-2 cm below bifurcation)
- the highest PSV and EDV obtainable around the stenosis
- From these velocities, the PSV Ratio (ICAPSV/CCAPSV or St Mary’s Ratio (ICAPSV/CCAEDV) may be calculated, but the original velocity measurements should always be quoted in the report.
- In the case of a large plaque in a large bulb measure and report the bulb diameter and the plaque thickness (residual lumen)
- Qualitatively note any calcification and irregular surface of plaque
- Record length of plaque
- Record the distance of the bifurcation below the mastoid process (cm)
- Record presence or otherwise of clear distal lumen
Note whether the distal ICA lumen is clear with colour filling and the nature of the flow i.e. pulsatile, turbulent or damped.
The presence of calcification, low echogenic plaque and any ulceration seen should be noted.
Table 15. Diagnostic Criteria
| Percentage stenosis NASCET | ICA Peak Systolic Velocity cm/sec | ICA PSV to CCA PSV ratio | ICA PSV to CCA EDV ratio |
| <50 | >125 | <2 | <8 |
| 50-59 | >125 | 2-4 | 8-10 |
| 60-69 | >125 | 2-4 | 11-13 |
| 70-79 | >230 | >4 | 14-21 |
| 80-89 | >230 | >4 | 22-34 |
| >90 but less than near occlusion | >400 | >5 | >35 |
| Near occlusion | High, low or string flow | Variable | Variable |
| Occlusion | No flow | Not applicable | Not applicable |
For the vertebral arteries, the direction of flow and waveform type, when pathological, should be recorded i.e. antegrade/retrograde and transient or full subclavian steel waveform. Where abnormal vertebral waveforms are found the maximum PSV in the proximal subclavian artery should be measured (normal <1.50 m/s).
Caution should be exercised in interpreting velocities when there is severe bilateral disease (arteriosclerosis) or when there is concurrent aortic valve disease. Where there is poor visualisation due to patient habitus, calcified vessels, or a firm conclusion is otherwise difficult or ambiguous, the report should note this and indicate that further imaging is required for a definitive diagnosis.
Lower/Upper Limb/Graft Arterial Ultrasound
Location and extent of disease should be reported including start of occlusion and point of reconstitution.
Velocities at discrete stenoses should be measured when there is a greater than two fold increase in PSV at the stenosis relative to the proximal PSV, indicating a > 50% stenosis. Values measured should be quoted in the report e.g. (1.2 to 4.7 m/s).
It may be appropriate to summarise the observations, for example: Generalised narrowing throughout the SFA-popliteal segment or uneven lumen throughout or SFA was ectatic.
Indicate the quality of the distal waveform e.g. Damped flow below knee or Flow remained good and pulsatile to ankle level.
Note the quality of the distal run-off i.e. are the vessels of normal/narrowed calibre at ankle, are posterior and anterior tibial arteries patent.
Ultrasound Investigation for Deep Vein Thrombosis (DVT)
- Note which veins have been assessed and record their compressibility and presence/absence of colour filling
- Note the presence/absence of phasic flow with respiration or Valsalva in proximal veins
- Note whether vigorous/sluggish enhanced flow is seen upon distal manual compression
- Where thrombus is identified, record its location and extent and whether there is any patency through the thrombus
Ultrasound Investigation for Varicose Vein
- Note occurrence and location of reflux in the LSV and SSV distributions. Include anterior thigh vein and Giacomini vein when seen
- Note the presence of incompetence at SFJ and SPJ
- Note occurrence of reflux in mid-thigh and large calf perforators
- Note any incompetence in distal popliteal vein (reflux >1 second) and gastrocnemius vein (when seen, usually runs to a perforator in the calf)
In the case of recurrent varicose veins, determine and report the source of any incompetence seen with reference to landmarks:
Example:
LSV absent, incompetent anterior thigh vein runs from SFJ to lateral border of knee, incompetent superficial vein runs from mid-thigh perforator 10 cm above knee, LSV present and incompetent from 6 cm below the SFJ with communicating vein to incompetent SFJ, large incompetent perforator 8 cm above medial malleolus.
Vein Marking for Harvesting or Other Pre-Surgery Ultrasound
With patient standing or sitting to ensure vein filling, determine location and measure diameter of vein (should be greater than 3-4 mm for use as graft). Marking is done with a water colour pencil and then marked in with a permanent marker as the gel is removed from the skin. Report should note vein diameter and location of adequate vein e.g. Good LSV to 8 cm below knee - greater than 4 mm throughout. Vein marked.