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Plaque estimate (diameter reduction) with gray-scale and color Doppler ultrasound. Note: This is the sonographer’s preliminary worksheet. For diagnosis, please refer to final report. Version.17 5.2017. Sonographer: MRN: DOB:

Ultrasound performed by: www.ultrasoundtraining.com.au @UTS_Australia UltrasoundTrainingSolutions 3rd Trimester Ultrasound Worksheet Age G P LMP ∴ Gestation W D Fetal Number E.D.D BPD LIQUOR VOLUME cm Normal / Increased / Decreased W D AFI HC LIQUOR VOLUME

COMPLETE OB ULTRASOUND Transabdominal Transvaginal MEASUREMENTS BPD _____ cm _____ %tile OFD _____ cm _____ %tile

Liver: Normal Enlarged Heterogeneous Coarse Fatty Surface: Smooth Lobulated Portal Vein Patent: Yes No Obscured Ascites: No Mild Mod Severe GB: Normal Absent Echogenic Focus(es) Stone(s) Mobile Fixed Shadow Sludge GB Wall Thickness: _____mm US Murphy’s Sign Pos Neg CBD: _____mm Pancreas: Normal Obscured (Head / Body / Tail)

COMPLETE 76700 LIMITED 76705 NOT A MEDICAL DOCUMENT PANCREAS HEAD: _____ BODY: _____ TAIL: _____ _____ _____ _____ AORTA at level of SMA: _____ cm IVC at level of ...

Ultrasound Worksheet History: Area of interest: _____ Comments: _____ SYNERGY RADIOLOGY ASSOCIATES

Portal Vein Flow: Hepatopedal – normal appearance of flow and doppler seen. Liver Comments: NAD/Normal - Homogeneous echotexture throughout, isoechoic to right renal cortex parenchyma, normal vascular appearance seen throughout.