Radiology Coding Alert

Order: Transvaginal pelvic ultrasound, check endometriosis

Report: Pelvic Ultrasound

Clinical: History of endometrial biopsy

Transabdominal as well as transvaginal including color Doppler evaluation of the pelvis was performed. The uterus is normal in size. The uterus is midline and anteverted and measures 8.8 x 3.2 x 5.6 cm. There is no intramural, endometrial or subserosal mass. The endometrial stripe is within the upper limits of normal measuring 6 mm. The cervix and vagina appear normal.

The uterus does contain multiple small fibroids. The largest fibroid measures 9 x 8 mm and involves the posterior body.

The left ovary is enlarged. The left ovary measures 3.5 x 2.5 x 2.3 cm. The left ovary is enlarged secondary to a complex left ovarian cyst measuring 2.7 x 2.2 cm. This is predominantly cystic but does have a nodular density within its base. The nodular density measures 1.1 x 1.5 cm. Doppler evaluation demonstrates a resistive index of 0.3 suggestive of low resistive blood flow.

The right ovary is normal measuring 2.2 x 1.1 x 1.0 cm.

There is no pelvic adenopathy or ascites.

1. Enlarged left ovary secondary to a complex left ovarian cyst measuring 3.5 x 2.5 x 2.3 cm. This has a solid nodular density within it. Doppler evaluation demonstrates low resistive flow. Correlation with CEA as well as CA-125 levels is suggested. A follow-up study in 4-6 weeks is suggested to verify stability or resolution of this complex cyst.

2. Fibroid uterus as discussed above.

3. The endometrial stripe is within the upper limits of normal at 6 mm.