Sample Dictations Color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was

performed. The left testicle measures 5.1 x 2.8 x 3.0 cm. There is no evidence of intratesticular masses. There is normal Doppler blood flow. The left epididymis has an unremarkable appearance. There is a trace hydrocele. The right testicle measures 5.3 x 2.4 x 3.2 cm. The epididymis has normal appearance. There is a trace hydrocele. No intratesticular masses or torsion is identified. There is no significant scrotal wall thickening. IMPRESSION: Trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination. Abdominal US Findings: The liver is normal in echogencity and size, measuring approximately [ ] cm in longitudinal dimension. No focal lesions are seen. The hepatic veins and portal veins are patent with appropriate directional flow. No intrahepatic ductal dilatation is seen. The gallbladder is not distended and has normal wall thickness. No pericholecystic fluid or gallstones are visualized. The sonographic Murphy's sign is negative. The common duct is not dilated with a diameter of [ ] cm. The visualized pancreas appears normal. No pancreatic ductal dilatation is visualized. The splenic vein is patent. The spleen is normal in echogenicity and size, measuring [] cm in longitudinal dimension. The right and left kidneys are normal in echogenicity and size, measuring [] and [] cm in longitudinal dimension, respectively. No hydronephrosis, renal mass or calculi are visualized. The visualized portion of the inferior vena cava is unremarkable. No abdominal aortic aneurysm is identified. Impression: []

Pelvic US Findings: The uterus measures [ ] x [ ] x [ ] cm. No focal uterine masses are seen. The endometrium measures [ ] cm in diameter. The right ovary measures [ ] cm x [ ] cm x [ ] cm. The left ovary measures [ ] cm x [ ] cm x [ ] cm. No adnexal lesion is seen. Normal right and left ovarian arterial and venous waveforms are idenitifed with normal resistive indices of [ ] and [ ], respectively. No free pelvic fluid is demonstrated. Impression: [] Kidneys Findings: The right kidney is normal in echogenicity and size, measuring [ ] cm in longitudinal dimension. No right hydronephrosis, mass or calculi are visualized. The right renal vein is patent. Arterial flow is demonstrated within the right kidney with a normal resistive index of [ ]. The left kidney is normal in echogenicity and size, measuring [ ] cm in longitudinal dimension. No left hydronephrosis, mass or calculi are visualized. The left renal vein is patent. Arterial flow is demonstrated within the left kidney with a normal resistive index of [ ]. Bilateral ureteral jets are seen within the bladder. Impression: [ ] Thyroid Findings: The left lobe is normal in size measuring [ ] x [ ] x [ ] cm. The right lobe is normal in size measuring [ ] x [ ] x [ ] cm. No nodules are seen. The isthmus is normal in size measuring [ ] in maximum AP diameter. No adjacent enlarged lymph nodes are seen. Impression: []

Scrotal Findings: The right testis measures [ ] x [ ] x [ ] cm and is of normal echotexture. No focal right testicular parenchymal lesions are visualized. Testicular arterial flow is visualized. The right epididymal head is normal in size measuring [ ] cm. The right epididymal body is normal in size measuring [ ] cm. No right hydrocele or varicocele is seen. The left testis measures [ ] cm and is of normal echotexture. No focal left testicular parenchymal lesions are visualized. Testicular arterial flow is visualized. The left epididymal head is normal in size measuring [ ] cm. The left epididymal body is normal in size measuring [ ] cm. No left hydrocele or varicocele is seen. Impression: [] REASON FOR EXAM: Left testicular swelling for one day. FINDINGS: The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm. The right epididymis measures up to 9 mm. There is a hydrocele on the right side. Normal flow is seen within the testicle and epididymis on the right. The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm. The left testicle shows normal blood flow. The left epididymis measures up to 9 mm and shows a markedly increased vascular flow. There is mild scrotal wall thickening. A hydrocele is seen on the left side. IMPRESSION: 1. Hypervascularity of the left epididymis compatible with left epididymitis. 2. Bilateral hydroceles. OBSTETRIC FINDINGS: A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There is normal amniotic fluid index of 12.2 cm. There is a 4-chamber heart. There is spontaneous body/limb motion. The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable. BIOMETRIC DATA: BPD = 7.77 cm = 31 weeks, 1 day HC = 28.26 cm = 31 weeks, 1 day AC = 26.63 cm = 30 weeks, 5 days FL = 6.06 cm = 31 weeks, 4 days Composite sonographic age 30 weeks 6 days plus minus 17 days.

ESTIMATED DATE OF DELIVERY: Month DD, YYYY. Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces. IMPRESSION: Single live intrauterine gestation without complications as described. DEMISE FINDINGS: By dates the patient is 8 weeks, 2 days. There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler. There is no fluid within the endometrial cavity. There is a 2.8 x 1.2cm right adnexal cyst. IMPRESSION: Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days. A preliminary report was called by the ultrasound technologist to the referring physician. GENERAL EVALUATION: Fetal Cardiac Activity: Normal with a heart rate of 135BPM Fetal Presentation: Cephalic. Placenta: Anterior Placentral grade: II Previa: ? None. Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios. BIOMETRY: BPD: 9.0cm consistent with 36weeks, 4days gestation HC: 34.6cm which equals 40weeks and 1day gestational age. FL: 6.9cm which equals 35weeks and 3days gestational age. AC: 34.6cm which equals 38weeks and 4days gestational age.

CI (BPD/OFD): (70-86) 73 FL/BPD: (71-87) 77 FL/HC: (20.8-22.6) 19.9 FL/AC (20-24) 20 HC/AC: (0.92-1.05) 1.00 GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days. FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces). ESTIMATED FETAL WEIGHT PERCENTILE: 24%. EDD BY CURRENT ULTRASOUND: 06/04/07. GESTATIONAL AGE BY DATES: 40weeks 0days. L M P: Unknown. EDD BY DATES: 05/18/07. DATE OF PREVIOUS ULTRASOUND: 03/05/07. EDD BY PREVIOUS ULTRASOUND: 05/24/07. FETAL ANATOMY: Fetal Ventricles: Normal Fetal Cerebellum: Normal Fetal Cranium: Normal Fetal Face: Normal Nose and Mouth Fetal Heart (4 Chamber View): Normal Fetal Diaphragm: Normal Fetal Stomach: Normal Fetal Cord: Normal three-vessel cord Fetal Abdominal Wall: Normal

Fetal Spine: Normal Fetal Kidneys: Normal Fetal Bladder: Normal Fetal Limbs: Normal IMPRESSION: Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days. AFI=4cm compatible with mild oligohydramnios. Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%. Placental grade is II. No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8. Renal Ultrasound INDICATION FOR STUDY: CT scan in March 2005 showed renal cyst. MEDICAL AND SURGICAL HISTORY: The patient has a history of high cholesterol. The patient also has history of thyroid cancer, both lobes removed and had lung surgery. ULTRASOUND FINDINGS: RIGHT KIDNEY: The right kidney measures 10.4 x 4.6 x 4.3 cm. Hydronephrosis is not seen. Echotexture is increased suggesting medical renal disease. LEFT KIDNEY: The left kidney measures 9.9 x 4.1 x 6.0 cm. Hydronephrosis is not seen. The echotexture is increased. There are two cysts seen:

In the mid-pole irregular and measuring 3.6 x 4.8 x 2.1 cm. Lower pole clear cyst seen measuring 9 x 8 mm.

Prominent pyramids are noted suggesting medical renal disease. IMPRESSION: Normal-sized kidneys are noted bilaterally with increased echotexture, prominent pyramids suggesting medical renal disease. No evidence of hydronephrosis is seen. There are two cysts seen in the left kidney; one measuring 3.8 cm x 4.8 x 2.1 cm, the other measuring 9 x 8 mm, one in the mid pole and another one in lower pole. Both are clear cysts. No other findings are noted.

Thyroid Ultrasound INDICATION FOR STUDY: Thyroid nodules. MEDICAL AND SURGICAL HISTORY: The patient has a history of thyroid disease. No other history is given. There is a family history of thyroid cancer. ULTRASOUND FINDINGS: RIGHT LOBE: The right lobe of the thyroid measures 4.2 x 1.4 x 2.2 cm, heterogeneous and nodular. No distinct masses are seen. No cysts are seen. ISTHMUS: The isthmus is normal. LEFT LOBE: The left lobe measures 4.2 x 2.2 x 2.0 cm, heterogeneous and nodular with a single mass seen in lower to mid-pole measuring 2.9 x 1.7 x 2.0 cm with calcifications, unchanged from previous exam. Cysts are not seen. IMPRESSION: Heterogeneous thyroid lobes are noted with a 2.9 cm left mid to lower pole mass seen, unchanged in size from previous examination of February 2005. Previous biopsy in 2002 showed thyroiditis, and in 2004 showed lymphoplasmacytic infiltrate suggestive of thyroiditis.

Pelvic Ultrasound INDICATION FOR STUDY: Followup on complex left ovarian cyst and sidewall cyst. MEDICAL AND SURGICAL HISTORY: The patient has a history of high cholesterol. The patient also has history of thyroid cancer, both lobes removed and had lung surgery. ULTRASOUND FINDINGS: UTERUS: The uterus measures 5.6 x 3.7 x 2.2 cm with a 3.6 cm corpus, anteverted in position with a single fibroid, anterior subserosal measuring 1.2 x 0.9 x 1.4 cm, new since previous exam. Endometrium is normal measuring 3 mm. RIGHT OVARY: The right ovary measures 1.1 x 2.0 x 0.9 cm, located lateral to the uterus with no significant follicle formation. LEFT OVARY: The left ovary measures 2.0 x 2.0 x 1.3 cm, lateral to the uterus with a retention cysts measuring 1.7 x 1.3 x 0.9 cm, unchanged from previous exam. On the left lateral sidewall, there is a clear cyst measuring 1.0 x 1.1 x 0.9 cm, unchanged in size since previous exam. It now appears to be a clear cyst.

IMPRESSION: Transabdominal and transvaginal ultrasound reveals a normal-sized uterus with a single fibroid not noted on previous exam measuring 1.2 x 0.9 x 1.4 cm. Normal endometrium is seen. Normal postmenopausal right ovary is identified. The left ovary is seen measuring normal size with a 1.7 x 1.3 x 0.9 cm, clear cyst unchanged from previous exam. On the left lateral sidewall, there is a 1.0 x 1.1 x 0.9 cm cyst that is unchanged in size from previous exam but now appears to be clear. No free fluid is noted. EXAM: Ultrasound Abdomen. REASON FOR EXAM: Elevated liver function tests. INTERPRETATION: The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration. The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed. There is dilatation of the common bile duct up to 1 cm. There is also dilatation of the pancreatic duct that measures up to 3 mm. There is caliectasis in the right kidney. The bladder is significantly distended measuring 937 cc in volume. The caliectasis in the right kidney may be secondary to back pressure from the distended bladder. The aorta is normal in caliber. IMPRESSION: 1. Dilated common duct as well as pancreatic duct as described. Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass. The findings could reflect changes of cholecystectomy. 2. Significantly distended bladder with probably resultant caliectasis in the right kidney. Clinical correlation recommended. CLINICAL HISTORY: RUQ pain. TECHNIQUE: Realtime sonographic images were obtained in multiple projections. COMMENTS: The visualized liver is of uniform echo texture without evidence of mass or defect. There is no intra or extrahepatic biliary ductal dilatation. The common bile duct measures up to 4 mm. The gallbladder is physiologically distended with multiple calculi. The gallbladder wall is thickened measuring 6 mm however there is no pericholecystic fluid. Reported positive murphy's sign. The visualized portions of the pancreas are unremarkable. IMPRESSION: Multiple gallstones with a thickened gallbladder wall and reported positive Murphy's sign. These

findings are concerning for acute or chronic cholecystitis. Please correlate clinically.