FIRST TRIMESTER ULTRASOUND REPORT
ULTRASOUND REPORT TO LMC
(if different reports are sent to the Laboratory and the LMC)
|Hospital No: | |
|Exam Date: | |
Dear ……………….
Thank you for referring your patient ………………………………………………………
…………………………………………………………………………………………………
|INDICATION: |Nuchal translucency scan. For first trimester combined screening. |
|History: |
|Maternal age: | |
|Last period: | |
|EDD by ultrasound: | |EDD by dates: | |
|Gestational age: | weeks + day |Gestational age by dates | W+ D |
|First Trimester Ultrasound: |
|Transabdominal US with Voluson E8 |Ultrasound view: | | |
|Fetal heart action present |Frequency | |bpm |
|Crown-rump length (CRL) | | |mm |
|Biparietal diameter (BPD) | | |mm |
|Nuchal translucency (NT) | | |mm |
| |
|Nasal bone (tick one or leave blank) | |Not looked for |
| | | |
| | | |
| | |Present |
| | |Absent |
| | |Not able to be visualised for technical reasons |
|Fetal anatomy: |
|Skull/brain heart spine abdomen stomach bladder |
|hands feet |
|Placenta: | |
|Amniotic fluid: | |
|Maternal Structures: |
|Right ovary: | |
|Left ovary: | |
|Summary: |
| |
| |
| |
|Name of Specialist: | |
|Sonographer Initials: | |
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