Chest / pleural ultrasound report template
A structured chest / pleural ultrasound report template used for chest / pleural ultrasound. It covers 4 sections and 20 fields, and includes a one-click normal preset.
Technique
Ultrasound of the pleural spaces and lung bases with low- and high-frequency transducers.
Sample normal chest / pleural ultrasound report
This is the text SonoTez generates when the doctor applies the template's normal preset. Measurements are left for the doctor to enter.
Technique
Ultrasound of the pleural spaces and lung bases with low- and high-frequency transducers.
Findings
Right hemithorax
No right pleural effusion.
Right lung sliding is present with an A-line pattern.
Left hemithorax
No left pleural effusion.
Left lung sliding is present with an A-line pattern.
Impression
No pleural effusion, consolidation or pneumothorax sign on either side.
What to include: sections and measurements
Right hemithorax
- Pleural effusion: none · present
- Character: anechoic · complex non-septated · complex septated · homogeneously echogenic
- Maximum interpleural distance (mm)
- Lung sliding: present · absent · absent with lung point
- B-lines: a-line pattern (0–2 per space) · ≥ 3 per intercostal space · confluent
- Consolidation: none · present · compressive atelectasis
- Diaphragm: normal movement · reduced / absent movement · paradoxical movement
Left hemithorax
- Pleural effusion: none · present
- Character: anechoic · complex non-septated · complex septated · homogeneously echogenic
- Maximum interpleural distance (mm)
- Lung sliding: present · absent · absent with lung point
- B-lines: a-line pattern (0–2 per space) · ≥ 3 per intercostal space · confluent
- Consolidation: none · present · compressive atelectasis
- Diaphragm: normal movement · reduced / absent movement · paradoxical movement
Site marking
- Site marked: yes · no
- Site
- Patient position
- Skin-to-fluid depth (mm)
- Fluid depth at site (mm)
Other findings
- Other findings
Writing the impression
Answer the clinical question first, list the remaining findings in order of importance, and keep anything new out of the impression. If a structure was not fully seen, say so and give the reason. See how to write an ultrasound report for wording and certainty terms.