General Practitioner Template

Shoulder Ultrasound Report

A professional General Practitioner template for healthcare professionals.

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Specialty

General Practitioner

Used

7 times

Type

Note

Last edited

2025/08/11

Created by

Amber Polley

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About this template

A Shoulder Ultrasound Report template is a structured document used by medical professionals, such as General Practitioners, to record the findings of a shoulder ultrasound examination. This template helps to systematically document the indication for the scan, the side examined, and detailed findings related to the biceps tendon, rotator cuff tendons (supraspinatus, infraspinatus, and teres minor), the acromioclavicular joint, the subacromial-subdeltoid bursa, and the glenohumeral joint. The report also includes an overall impression and recommendations for follow-up. With Heidi, this template can be quickly populated from a patient's visit transcript, streamlining the documentation process.

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Indication: The patient presented with left shoulder pain and limited range of motion, with a suspected rotator cuff tear. Side: Left Findings 1. Biceps Tendon Location: In groove Appearance: Normal echotexture 2. Subscapularis Tendon Appearance: Normal 3. Supraspinatus Tendon Appearance: Partial-thickness tear 4. Infraspinatus and Teres Minor Tendons Appearance: Normal 5. Acromioclavicular (AC) Joint Joint Space: Normal Joint Degeneration: Mild Other Findings: None 6. Subacromial-Subdeltoid (SASD) Bursa Fluid Collection: Mild distension 7. Glenohumeral Joint Joint Effusion: Absent Other Findings: None Additional Findings: None Impression Overall Summary: Findings consistent with partial-thickness tear of the supraspinatus and mild bursitis. Suggested Follow-up or Recommendations: Referral to orthopedics for further evaluation and management. Consider repeat ultrasound in 6-8 weeks if symptoms persist.