Radiologist-Vorlage
USG Abdomen (Abnormal)
Eine professionelle Radiologist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This USG Abdomen (Abnormal) template is designed for sonologists and radiologists to document ultrasound examinations of the abdomen. It includes sections for patient information, clinical indications, technical details, and detailed findings. The template ensures comprehensive documentation of the pancreas, liver, gallbladder, kidneys, and spleen, highlighting both normal and abnormal findings. This template is ideal for radiologists looking for a structured format to report abdominal ultrasound results in abnormal cases, ensuring all critical aspects are covered. Use this template to streamline your ultrasound reporting process and maintain high standards of clinical documentation.
Vorlagenvorschau
Ultrasound Abdomen
Patient Information:
Name: John Doe
Age & Gender: 45, Male
Date of Birth: 01/01/1978
Medical Record Number: 123456
Clinical Indication:
Patient presents with upper abdominal pain and jaundice. History of gallstones.
Technical Information:
Date of Examination: 10/10/2023
Sonographer: Jane Smith
Equipment Used: GE Logiq, curvilinear transducer operating at 2-5MHz
Type of Examination: Ultrasound Abdomen
Findings:
The pancreas is well visualised and has a normal size, shape and echotexture, with no duct dilation.
The liver is of normal size, shape and echotexture with no intrahepatic duct dilation or focal lesion seen. The portal vein measures 12 mm with normal flow.
The gallbladder is normal with a wall thickness of 3 mm. No gallstones, polyps or sludge are seen within the lumen and the patient is sonographic Murphy’s negative. The CBD measures 6 mm.
Both kidneys are of normal size and shape with smooth contour and normal cortical echotexture. The central echogenic complexes have a normal appearance with no hydronephrosis. The right kidney measures 10 x 5 cm and the left kidney measures 10 x 5 cm.
The spleen is of normal size, shape and echotexture with a diameter of 11 cm.
Impression:
- Normal abdominal ultrasound with no evidence of gallstones or ductal dilation.
- No focal liver lesions or intrahepatic duct dilation.
- Normal renal and splenic morphology.
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