Pinnacle Health System



RENAL ULTRASOUND WORKSHEET

Aorta: Maximum AP Diameter:________cm

□ Plaque

□ Dilatation

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Name:____________________________________________ Date:_____/_____/____ ID:_________________

DOB: _____/______/______ Age:______ Sex: M / F Referring Physician:_________________________

Indications:__________________________________________________________________ Tech:_________

Height: _____________ Weight:______________ BP:_______/________

[pic]

Right Kidney: _______ X _______ X _______cm

R/I:______________

□ Abnormal Echogenicity

□ Decreased Size

□ Cyst

□ Mass

□ Echogenic Focus

□ Dilated pelvis/ureter

[pic]

Left Kidney: _______ X _______ X _______cm

R/I:______________

□ Abnormal Echogenicity

□ Decreased Size

□ Cyst

□ Mass

□ Echogenic Focus

□ Dilated pelvis/ureter

Bladder:

( Unable to evaluate

Wall Thickness:_______cm

( Ureteral Jets Seen: RT / LT

Pre-Void Volume_____________cc

Post Void Volume_____________cc

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