Limited Abdominal Ultrasound
Procedure: Limited Abdominal Ultrasound – evaluation for small bowel obstruction
Performed and interpreted by me; images recorded and archived
Indication: Abdominal distention, vomiting and concern for small bowel obstruction
Findings:
– [Multiple dilated loops of bowel]
– [Peristalsis noted]
– [No free fluid noted]
Interpretation: Small bowel obstruction [highly] likely
Signed by
_____________________M.D.
My RUQ Ultrasound
Procedure: Limited Abdominal Ultrasound – Right Upper Quadrant
Preformed and interpreted by me; images recorded and archived
Indication: Right upper quadrant/epigastric pain/flank pain
Findings:
– [No] Gallstones
– [No] pericholecystic fluid
– [Normal] gallbladder wall thickness
– [Common Bile duct] [Normal]
Interpretation: [Normal right upper quadrant ultrasound]; [no evidence of gallstones]; [no evidence of cholecystitis]
Signed by
_______________________________ M.D.
My Bladder ultrasound
Self performed and read
Image archived
Location; pelvis
Indication: [Rule out obstruction][measure bladder volume]
Probe curvilinear
#1: Bladder identified
#2: No free fluid noted
#3: [Bladder jets identified]
#4: [Post void residual]
Impression: [ ]
Signed by
_______________________MD
Bladder ultrasound Post Void Residual
Self performed and read
Image archived
Location; pelvis
Indication: [measure bladder volume post void]
Probe curvilinear
#1: Bladder identified
#2: No free fluid noted
#3: [Post void residual]
Impression: [ ]
Signed by
_______________________MD
My Aorta Ultrasound
Procedure Note: Retroperitoneal Ultrasound – Aortic Study
Self-performed and read by me.
Image archived
Location: Abdomen
Indication: Eval for AAA
Probe: phased array
#1: [Aorta identified]
#2: [No evidence of aneurysm]
#3: [No evidence of aortic rupture]
Impression: [No aneurysm seen on Ultrasound]
Signed by
____________________ M.D.
Ultrasound: Soft-Tissue
Self-performed and read
Image archived
Location: Skin [ ]
Indication: Consideration of Abscess vrs cellulitis
Probe: Linear
#1: Identification of dermis/subcutaneous tissues done
#2: Abscess [seen]
#3: Edema [seen] consistent with cellulitis
Impression: abscess [confirmed]
Signed by
______________________MD
Intraoral Ultrasound Exam for Peritonsillar Abscess
-Self-performed and archived
[Intraoral Evaluation with Intracavitary Probe: After adequate anesthesia obtained with topical agent the probe was inserted and the area of interest was evaluated]
[Transcutaneous with Linear Probe: The probe was placed under the angle of the mandible with the marker facing the patient’s ear.]
- Anatomical Structures identified
- [Abscess site identified]
- Color Doppler applied to evaluate and localize vessels
- [Relationship of the carotid artery to the abscess noted]
Signed by
__________________MD
Vascular Ultrasound of lower extremity veins
Self-performed and read
Image archived
Location: Lower extremities
Indication: Suspected DVT
Probe: Linear
#1: [Normal compressible femoral vein with doppler flow]
#2: [Normal compressible popliteal veins with doppler flow]
#3: [No luminal clot seen]
Impression: [No DVT appreciated]
Signed by:
_______________________ MD
My Arthrocentesis w/US Guidance
PROCEDURE NOTE: ARTHROCENTESIS
Ultrasound Guided: [Yes]
Joint: [Right][left] [specify joint]
Indication: [Evaluation of] effusion
Anesthesia: local, 1% lidocaine
Technique: After informed consent was obtained the area was cleansed and prepped in a normal aseptic technique. Needle introduced into the joint space.
Fluid: [mL]. [Appearance].
Complications: none
PROCEDURE: Ultrasound guidance of needle placement
Indication: Guidance of needle for procedure
Performed and interpreted by myself
Findings:
- [Targeted structure identified]
- [Distance from the skin noted]
- [Surrounding vascular and nerve structures noted]
Interpretation: Ultrasound guidance of needle to increase safety and accuracy of procedure.
Signed by
____________________, M.D.
My abscess ultrasound
Ultrasound: Soft-Tissue
Self-performed and read
Image archived
Location: Skin [ ]
Indication: Consideration of Abscess vrs cellulitis
Probe: Linear
#1: Identification of dermis/subcutaneous tissues done
#2: Abscess [seen]
#3: Edema [seen] consistent with cellulitis
Impression: abscess [confirmed]
Signed by
_____________________ MD
Procedure Note: Point of care bedside echocardiogram
Self-performed and read
Image archived
Location: Chest
Indication: [Cardiac Arrest][Suspected CHF][concern for shock or hypovolemia][Trauma]
Probe: phased array
[- Cardiac contour identified]
[- No evidence of pericardial tamponade]
[- No significant cardiac motion detected]
[- No obvious wall motion abnormalities]
[- Appearance of normal contractile thickening]
[- No obvious cardiomegaly]
[- No pericardial fluid seen]
Impression: [cardiac arrest with no cardiac activity][ No evidence of severe CHF though mild abnormalities could not be assessed in the brief study][No evidence of cardiac dysfunction seen on echo][No tamponade or effusion]
Signed by:
____________________ MD
My Cardiac Ultrasound – Extensive
Procedure Note: Point of care bedside echocardiogram
Self-performed and read
Image archived
Location: Chest
Indication: [Cardiac Arrest][Suspected CHF][concern for shock or hypovolemia][Trauma]
Probe: phased array
[- Cardiac contour identified]
[- No evidence of pericardial tamponade]
[- No significant cardiac motion detected]
[- No obvious wall motion abnormalities]
[- Appearance of normal contractile thickening]
[- No obvious cardiomegaly]
[- No pericardial fluid seen]
Impression: [cardiac arrest with no cardiac activity][ No evidence of severe CHF though mild abnormalities could not be assessed in the brief study][No evidence of cardiac dysfunction seen on echo][No tamponade or effusion]
Signed by:
____________________ MD
Procedure Note: Point of care bedside echocardiogram
Self-performed and read
Image archived
Location: Chest
Indication: [Cardiac Arrest][Suspected CHF][concern for shock or hypovolemia][Trauma]
Probe: phased array
[- Cardiac contour identified]
[- No evidence of pericardial tamponade]
[- No significant cardiac motion detected]
[- No obvious wall motion abnormalities]
[- Appearance of normal contractile thickening]
[- No obvious cardiomegaly]
[- No pericardial fluid seen]
Impression: [cardiac arrest with no cardiac activity][ No evidence of severe CHF though mild abnormalities could not be assessed in the brief study][No evidence of cardiac dysfunction seen on echo][No tamponade or effusion]
Signed by:
_________________ MD
Procedure Note: Chest Ultrasound
Self-performed and read
Image archived
Location: Chest – [Bilateral] [anterior] [axillary] [posterior]
Indication: Evaluation for [Pulmonary Edema]/[Pleural Effusion]
Probe: [phased array][Linear]
– [normal sliding sign]
– [B lines suggestive of pulmonary edema]
– [No pleural effusions seen]
Impression:
– [Pulmonary Edema]
– [No] [Pleural Effusion]
Signed by
_____________________, MD
Procedure Note: Chest Ultrasound
Self-performed and read
Image archived
Location: Chest – [Bilateral] [anterior] [axillary] [posterior]
Indication: Evaluation for [Pleural Effusion]/[Pneumonia]
Probe: [phased array][Linear]
[- Normal sliding sign]
[- No pleural effusions seen]
[- No hepatization seen]
[- Hepatization seen; consistent with Pneumonia]
[- No air bronchograms to suggest consolidation]
[- Air bronchograms present; suggestive of consolidation]
[- No bright shimmery columns to suggest air bronchograms]
[- Bright shimmery columns present; suggestive of air bronchograms]
Impression:
– [No] [Pneumonia]
– [No] [Pleural Effusion]
Signed by
_____________________MD
[PROCEDURE: ULTRASOUND EVALUATION OF SHOCK AND HYPOTENSION]
Procedure Note: Point of care bedside echocardiogram
Location: Chest
Indication: Suspected CHF or concern for shock or hypovolemia
Probe: phased array
[- Cardiac contour identified]
[- No obvious wall motion abnormalities]
[- Appearance of normal contractile thickening]
[- No obvious cardiomegaly]
[- No pericardial fluid seen]
[- EPSS Measured and] [less than 0.7cm; estimated EF >50%]
Impression:
[No evidence of cardiac dysfunction seen on echo]
[No tamponade or effusion]
Signed by
____________________MD
Procedure Note: Chest Ultrasound
Location: Chest – Bilateral anterior
Indication: Evaluation for Pneumothorax and/or Pulmonary Edema
Probe: phased array
[- normal sliding sign]
[- normal comet tails]
[- normal pleural line]
Impression:
[- No Pneumothorax]
[- No Pulmonary Edema]
Signed by
_________________MD
Procedure Note: Limited Abdominal Vascular Ultrasound for Evaluation of IVC
Location: epigastric/RUQ
Indication: [Evaluation of volume status]
Probe: Phased array
#1: IVC seen, diameter recorded
#2: IVC collapse [with inspiration] [None][Less than 50%][50% or greater]
#3: Shape was [oval, normal][flat, hypovolemia][full circular, possible hypervolemia]
Impression:[Euvolemia][Hypervolemia][Hypovolemia]
Signed by
_____________________MD
Procedure Note: Retroperitoneal Ultrasound – Aortic Study
Location: Abdomen
Indication: Eval for AAA
Probe: phased array
#1: [Aorta identified]
#2: [No evidence of aneurysm]
#3: [No evidence of aortic rupture]
Impression:
[No aneurysm seen on Ultrasound]
Signed by
___________MD
LIMITED ABDOMINAL ULTRASOUND: Free Fluid Evaluation
Self-performed and read
Images archived
Indication: Trauma and / or Hypotension
- [No Free fluid seen in the hepatorenal space (Morison’s Pouch)]
- [No Free Fluid seen in the splenorenal space (LUQ)]
- [No Free Fluid seen in the suprapubic region (Pelvis)]
Impression:
[No evidence of intraperitoneal free fluid].
Signed by
__________________MD
Vascular Ultrasound of lower extremity veins by EM Physician
Location: Lower extremities
Indication: Suspected DVT
Probe: Linear
#1: [Normal compressible femoral vein with doppler flow]
#2: [Normal compressible popliteal veins with doppler flow]
#3: [No luminal clot seen]
Impression: [No DVT appreciated]
Signed by
_________________MD
Dictation Room 