Ultrasound upper abdomen report template
A structured ultrasound upper abdomen report template used for ultrasound upper abdomen, ultrasound spleen. It covers 10 sections and 64 fields, and includes a one-click normal preset.
Technique
Real-time transabdominal ultrasound of the abdomen was performed.
Sample normal ultrasound upper abdomen 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
Real-time transabdominal ultrasound of the abdomen was performed.
Findings
Liver
The liver shows homogeneous echotexture with normal echogenicity and smooth margins.
Intrahepatic biliary radicles are not dilated.
No focal liver lesion is seen.
Gallbladder
The gallbladder is well distended with normal wall thickness. No calculus or sludge is seen.
Common bile duct
The common bile duct is not dilated.
Pancreas
The pancreas is normal in size and echotexture.
No focal pancreatic lesion is seen.
Spleen
Splenic echotexture is homogeneous with no focal lesion.
Right kidney
Corticomedullary differentiation is maintained with normal cortical echogenicity.
No hydronephrosis.
No calculus is seen.
Left kidney
Corticomedullary differentiation is maintained with normal cortical echogenicity.
No hydronephrosis.
No calculus is seen.
Free fluid
No free fluid is seen in the peritoneal cavity.
No pleural effusion is seen on either side.
Impression
No significant sonographic abnormality is seen in the structures examined.
What to include: sections and measurements
Liver
- Craniocaudal span (cm)
- Echotexture: homogeneous · coarse · heterogeneous
- Echogenicity: normal · increased · decreased
- Degree (doctor-assessed): mild · moderate · marked
- Surface / margins: smooth · irregular · nodular
- Intrahepatic biliary radicles: not dilated · dilated
- Portal vein diameter (mm)
- Focal lesion: none seen · present
Liver lesions repeatable
- Segment / location
- Appearance: simple-appearing cyst · complex cystic · hyperechoic solid · hypoechoic solid · isoechoic solid · calcified …
- Length (mm)
- Width (mm)
- Additional description
Gallbladder
- Distension: well distended · partially distended · contracted
- Wall: normal thickness · thickened
- Wall thickness (mm)
- Calculi: none seen · present
- Number: single · multiple
- Largest calculus (mm)
- Sludge: absent · present
- Pericholecystic fluid: absent · present
- Polyp: none seen · present
- Largest polyp (mm)
Common bile duct
- Diameter (mm)
- Calibre: not dilated · dilated
- Intraductal calculus: none seen · present
Pancreas
- Size and echotexture: normal · bulky · atrophic · heterogeneous
- Pancreatic duct: not dilated · dilated
- Focal lesion: none seen · present
- Lesion description
Spleen
- Bipolar length (cm)
- Echotexture: homogeneous · heterogeneous
- Focal lesion: none seen · present
- Lesion description
Right kidney
- Length (mm)
- Width (mm)
- Thickness (mm)
- Parenchymal thickness (mm)
- Corticomedullary differentiation: maintained · reduced · lost
- Cortical echogenicity: normal · increased
- Pelvicalyceal system: not dilated · mildly dilated · moderately dilated · severely dilated
- Calculi: none seen · present
- Largest calculus (mm)
- Calculus location
- Cyst: none seen · present
- Cyst description
Left kidney
- Length (mm)
- Width (mm)
- Thickness (mm)
- Parenchymal thickness (mm)
- Corticomedullary differentiation: maintained · reduced · lost
- Cortical echogenicity: normal · increased
- Pelvicalyceal system: not dilated · mildly dilated · moderately dilated · severely dilated
- Calculi: none seen · present
- Largest calculus (mm)
- Calculus location
- Cyst: none seen · present
- Cyst description
Free fluid
- Free fluid: none seen · present
- Amount (doctor-assessed): small · moderate · large
- Location
- Appearance: anechoic · with internal echoes · septated
- Pleural effusion: none seen on either side · right · left · bilateral
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.