Report Critique
Good? Acceptable? Poor? 26/10/2015 US Pelvis transvaginal Age:44yrs
Clinical details: Menorrhagia ++. Previous polyp. ? fibroids.??Cause
Report: 44 Year old female. LMP 22/10/2015 Clinical details confirmed with patient as above. No additional verbal history given
The endometrium measures 7mm in AP diameter. There is a focal area of altered echo pattern within the cavity measuring 14mm in length x 6mm AP. This has a blood supply and appearances are most likely to represent a small polyp
The anteverted uterus is normal in size and appearance.
Both ovaries are normal in size and appearance. No adnexal masses or free fluid.
Conclusion::Probable endometrial polyp present as a cause of symptoms Good 17/11/2014 US Pelvis transvaginal Age: 35yrs
Clinical Details: H/o breast Ca, family history of ovarian Ca, annual screening scan.
Report: The uterus is retroverted and normal in size. The myometrial echo pattern is somewhat heterogeneous with a discrete 1.3 cm fibroid within the posterior uterine wall. I note that an anterior wall fibroid was reported in Dec. 2013 but this is less evident today.
The endometrium is heterogeneous demonstrating some cystic areas but is of normal thickness at 6 mm. No significant internal vascularity.
No adnexal mass detected.
Acceptable 26/10/2015 US Pelvis transvaginal Age: 67 yrs
Clinical Details: Bloating ? cause ? ovarian symptoms
Report: With permission.
Sonographically normal cervix. Normal appearances and size of the uterus. Endometrium is thin in outline regularly at 2 mm AP diameter
Neither ovary is seen. No pelvic free fluid. No pelvic masses.
Poor 09/04/2015 US Pelvis transvaginal Age : 72yrs
Clincial details: PMB
Report:
TV scan with patient's consent. Maximum LS AP diameter of uterus = 39mm Maximum transverse diameter of uterus =49mm . The endometrium is difficult to define for measurement but it does appear to be distended by an irregular fluid collection measuring 21mm AP.
No obvious adnexal masses 13/04/2015 US Abdomen & pelvis Age :48 yrs
Clinical Details: Bloating Smoker.Cause unclear
Report: Normal appearances of liver, spleen, kidneys and CBD. The gallbladder contains a calculus ( thick walled). Pancreas obscured by bowel gas. Small amount of free fluid seen in abdomen and pelvis.
Normal appearances of uterus and endometrium. AP diameter of endometrium is 6 mm.
There is a complex mass above the uterus measuring 85mm x 125mm x 60mm. Ovaries not identified separate from mass. Appearances are highly suspicious of ovarian malignancy. Urgent gynaecological referral is suggested.
Report faxed to GP. 06/07/2015 US Pelvis Age :48 yrs
Clinical Details: Pain and mass in lower abdomen,slightly raised CA125
Report:
Central pelvis mass,10.8 x 13 x 9.8cms containing solid and fluid elements.This may represent haemorrhage into the mass.Pelvic organs have not been well visualised seperately.This may represent a fibroid mass with haemorrhage or a complex ovarian mass.Further imaging is needed.Patient discussed with Dr T ….,Consultant Radiologist and referring cliniican. 30/06/2015 US Pelvis (Transvaginal) Age :64yrs
Clinical Details: Previous TAH for endometrial Ca. Now new prolapse symptoms. TV Scan please
Report:
TA scan Previous TAH noted ?BSO?
The urinary bladder outlines normally. I am unable to comment on the bowel. No free fluid. 06/07/2015 US Pelvis transvaginal Age :25yrs
Clinical Details: Lower abdominal pain, cyclical ? Cause
Report: 25 year old, LMP 12 days ago
Adjacent to the left ovary there is mass of mixed echogenicity. There are some solid areas although it is predominantly cystic with smooth and thin walls. This mass measures 50 x 50 mm. I am uncertain as to the nature of this mass but in view of it’s benign appearance at this time I advise a rescan in 6 weeks. Please request if required Otherwise both ovaries are normal in size and appearance.
The uterus is normal in size and appearance. The endometrium is not thickened and demonstrates normal appearances for day 12 of cycle.
Conclusion: Left adnexal mass. Uncertain aetiology, rescan suggested in the first instance. Please request if required
I have discussed the results with the pt and asked her to contact you for further advise 25/09/2015 US Pelvis Age 30yrs
Clinical Details :Neonatal nurse.Adnexal mass on US,repeat scan in 3/12 recommended.
Report:
LMP 25.9.15
Patient scanned transabdominally and transvaginally with consent . Retroverted uterus.The uterus and right ovary appear sonographically normal. The previously reported left adnexal mass appears unchanged since the scan of January 2015.This suggests that this represents a dermoid cyst .It was difficult to demonstrate the left ovary. A trace of free fluid is seen in the pelvis.No renal dilatataion seen.
Images discusssed with Dr M…(Consultant Radiologist) who agreed with the above findings and suggests that if further characterisation of the mass is needed an MRI scan could be arranged 28/10/2015 US Abdomen and Pelvis Age :60 yrs
Clinical Details: Discussed in MDT.?omental disease to biopsy
Report:
There are some surface deposits on the liver but no ascites or omental cake.The right ovary is a bit bigger than normal and I have explained I will attempt a biopsy under ultrasound control tomorrow. . 09/09/2015 US Pelvis transvaginal Age :25yrs
Clinical Details: Chronic pelvic pain and dyspareunia.
Report:
The uterus and both ovaries appear normal.There is a small amount of pelvic free fluid within the Pouch of Douglas but this is within normal limits. No adnexal masses seen. No evidence of renal tract dilatation. What Makes a Good Report?
• Clear & Succinct • Relevant • Can be understood by the referrer • Answers clinical question • Draws conclusions • Suggests management if applicable • States any input from other staff • States what you have said to the patients (if applicable) • States what you have done with the report (if applicable) Summary
• Answer the question posed • Take time over report writing – it’s an indicator of you and your skills • Seek advice if needed • Enjoy the experience. • Good luck! BMUS would like to thank you for attending and the faculty for their input into this study day
See you again in 2016!