Ultrasound female pelvis (transabdominal) report template
A structured ultrasound female pelvis (transabdominal) report template used for ultrasound lower abdomen / pelvis, female pelvis, transabdominal, targeted uterine / adnexal assessment. It covers 13 sections and 58 fields, and includes a one-click normal preset.
Technique
Transabdominal ultrasound of the pelvis was performed with a full urinary bladder.
Sample normal ultrasound female pelvis (transabdominal) 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
Transabdominal ultrasound of the pelvis was performed with a full urinary bladder.
Findings
Uterus
The myometrium is homogeneous.
No fibroid is seen.
Cervix
The cervix appears normal.
Right ovary
Texture: normal.
No right ovarian lesion is seen.
Left ovary
Texture: normal.
No left ovarian lesion is seen.
Pouch of Douglas
No free fluid in the pouch of Douglas.
What to include: sections and measurements
Urinary bladder
- Distension: adequately distended · poorly distended · empty
- Wall: normal thickness · thickened · trabeculated
- Wall thickness (mm)
- Contents: anechoic · internal echoes / debris · calculus · intraluminal lesion
Uterus
- Position: anteverted · retroverted · axial
- Length (cm)
- AP (cm)
- Width (cm)
- Volume (mL) calculated
- Myometrium: homogeneous · heterogeneous
- Fibroids: none seen · present
Fibroids repeatable
- Location: subserosal · intramural · submucosal · pedunculated · cervical
- Wall: anterior · posterior · fundal · right lateral · left lateral
- Size 1 (mm)
- Size 2 (mm)
- Description
Endometrium
- Thickness (double layer) (mm)
- Appearance: trilaminar · homogeneous echogenic · heterogeneous · fluid in cavity
- Focal abnormality: none seen · present
- Description
Cervix
- Length (mm)
- Appearance: normal · bulky · fluid in canal · nabothian cyst(s) · focal lesion
- Description
Uterine cavity contents
- Gestational sac: none seen · present - use an obstetric template
- Retained products: none seen · echogenic material - possible retained products
Right ovary
- Length (cm)
- Width (cm)
- Height (cm)
- Volume (mL) calculated
- Texture / appearance: normal · bulky · heterogeneous
- Follicles (as seen)
- Largest / dominant follicle (mm)
- Cyst / mass: none seen · present
Right ovarian lesions repeatable
- Appearance: unilocular cyst · multilocular cyst · solid · mixed cystic-solid · other
- Size 1 (mm)
- Size 2 (mm)
- Features: septations · solid component · internal echoes · internal vascularity on colour doppler · calcification
- Description
Left ovary
- Length (cm)
- Width (cm)
- Height (cm)
- Volume (mL) calculated
- Texture / appearance: normal · bulky · heterogeneous
- Follicles (as seen)
- Largest / dominant follicle (mm)
- Cyst / mass: none seen · present
Left ovarian lesions repeatable
- Appearance: unilocular cyst · multilocular cyst · solid · mixed cystic-solid · other
- Size 1 (mm)
- Size 2 (mm)
- Features: septations · solid component · internal echoes · internal vascularity on colour doppler · calcification
- Description
Pouch of Douglas
- Free fluid: none seen · present
- Description
Ovarian morphology assessment (indication-specific)
- Right ovary follicle count (as counted)
- Left ovary follicle count (as counted)
- Follicle distribution: peripheral · scattered
- Counting method / approach
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.