Patient Information
- Owner: Ms. Eleanor Vance
- Patient's full name: "Buddy"
- Species: Canine
- Breed: Golden Retriever
- Age: 8 years
- Sex: Male (neutered)
- Weight: 32 kg
Date of Examination
01/11/2024
Reason for Ultrasound
Buddy presented with a two-week history of intermittent vomiting, reduced appetite, and mild abdominal discomfort. Blood work revealed elevated liver enzymes and mild anaemia. Abdominal palpation was unremarkable. An abdominal ultrasound was requested to investigate the gastrointestinal tract, liver, and other abdominal organs for potential underlying pathology contributing to the clinical signs.
1. Liver
- Liver is mildly enlarged with rounded margins; approximately 10.5 cm in length at its widest point. No significant size abnormalities relative to breed and body size noted.
- Liver echogenicity is diffusely heterogeneous, appearing slightly hyperechoic compared to the spleen with a coarse echotexture.
- Multiple hypoechoic, ill-defined nodules, ranging from 1-2 cm in diameter, are noted throughout both hepatic lobes, suggestive of diffuse hepatic changes.
2. Gallbladder and Biliary System
- Gallbladder is mildly distended with a wall thickness of 1.5 mm, which is within normal limits. Luminal contents show mild biliary sludge but no choleliths.
- Common bile duct is not dilated (2 mm diameter), and no obvious obstruction is identified.
3. Spleen
- Spleen is within normal size limits for the patient's breed (14 cm length). Echogenicity is homogenous and fine. No focal lesions or diffuse abnormalities detected.
4. Pancreas
- Pancreas appears mildly hyperechoic with slightly irregular margins, suggestive of mild inflammatory changes. The surrounding mesenteric fat is also mildly hyperechoic, consistent with localized inflammation.
5. Kidneys
- Right kidney measures 6.5 cm x 3.8 cm, with good corticomedullary distinction. Renal pelvis is not dilated. No masses or cysts identified.
- Left kidney measures 6.8 cm x 4.0 cm, with good corticomedullary distinction. Renal pelvis is not dilated. No masses or cysts identified.
6. Urinary Bladder
- Bladder wall thickness is within normal limits (2 mm). Luminal contents are anechoic with a small amount of sediment. No uroliths or masses are present.
7. Gastrointestinal Tract
- Stomach wall thickness is normal (4 mm) with appropriate layering. Contains a small amount of anechoic fluid and gas.
- Small intestinal wall thickness is within normal limits (3 mm for jejunum) with preserved layering. Peristalsis is normal. No foreign bodies or obstructive lesions are noted. Large intestinal walls are unremarkable.
8. Adrenal Glands
- Right adrenal gland measures 0.6 cm x 0.3 cm, normal shape and echogenicity.
- Left adrenal gland measures 0.7 cm x 0.4 cm, normal shape and echogenicity.
9. Reproductive Organs
- Prostate is moderately enlarged (4 cm diameter), diffusely hyperechoic, and slightly heterogenous, consistent with benign prostatic hyperplasia.
10. Abdominal Vessels
- Abdominal aorta and caudal vena cava appear patent with normal flow characteristics. No abnormalities noted.
11. Other Findings
- No peritoneal effusion detected.
- No significant abdominal masses or lymphadenopathy are identified beyond the noted hepatic changes.
- Incidental finding: Mild diffuse prostatic enlargement consistent with benign prostatic hyperplasia.
Interpretation
Abdominal ultrasonography reveals diffuse hepatic changes consistent with hepatopathy, characterized by heterogeneous echogenicity and multiple small hypoechoic nodules. While non-specific, these findings warrant further investigation to rule out inflammatory, metabolic, or neoplastic processes. Mild pancreatitis and benign prostatic hyperplasia were also identified as incidental findings, which may contribute to Buddy's discomfort but are unlikely to be the primary cause of his vomiting and elevated liver enzymes. The lack of overt gastrointestinal obstruction or significant foreign bodies is reassuring.
Diagnosis
Diffuse Hepatopathy; Mild Pancreatitis; Benign Prostatic Hyperplasia.
Recommendations
- Recommend liver biopsy or fine needle aspirate for definitive diagnosis of the hepatic changes.
- Consider a course of dietary management and pain relief for mild pancreatitis.
- Discuss options for managing benign prostatic hyperplasia, such as medical therapy with Finasteride.
- Recheck blood work in 2-4 weeks to monitor liver enzyme levels.
- Schedule a follow-up consultation to discuss biopsy results and treatment plan.
Report Prepared By
Dr. Sarah O'Connell, DVM
Date of Report
01/11/2024
Patient Information
[Owner name and surname] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
[Patient's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
[Species of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
[Breed of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
[Age of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
[Sex of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
[Weight of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
Date of Examination
[Date of the ultrasonography examination in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Reason for Ultrasound
[Clinical reason or presenting complaint necessitating the ultrasound examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
1. Liver
- [Size of the liver and any abnormalities relative to species and body size] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Liver echogenicity and echotexture including comparison to the spleen if noted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Focal hepatic lesions or diffuse hepatic changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
2. Gallbladder and Biliary System
- [Gallbladder size, wall thickness and luminal contents] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Biliary duct size or presence of obstruction] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
3. Spleen
- [Splenic size, echogenicity and any focal or diffuse abnormalities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
4. Pancreas
- [Pancreatic size, echogenicity and any abnormalities including changes in the surrounding mesenteric fat] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
5. Kidneys
- [Right kidney size, shape, corticomedullary distinction and any abnormalities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Left kidney size, shape, corticomedullary distinction and any abnormalities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
6. Urinary Bladder
- [Bladder wall thickness, luminal contents and presence of any abnormalities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
7. Gastrointestinal Tract
- [Stomach wall thickness, layering and contents] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Small and large intestinal wall thickness, layering, motility and any abnormalities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
8. Adrenal Glands
- [Right adrenal gland size, shape and echogenicity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Left adrenal gland size, shape and echogenicity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
9. Reproductive Organs
- [Uterus and ovaries including size and any abnormalities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Prostate including size, echogenicity and any abnormalities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
10. Abdominal Vessels
- [Abdominal aorta and caudal vena cava findings if abnormalities are noted] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
11. Other Findings
- [Presence, absence and characteristics of peritoneal effusion] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Presence, absence and description of abdominal masses or lymphadenopathy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
- [Any additional incidental findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a single bullet point.)
Interpretation
[Concise summary of the significant ultrasound findings, their clinical implications and how they relate to the patient's presenting symptoms or suspected conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Diagnosis
[Document the clinician's explicitly stated ultrasonography diagnosis based on the findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in paragraphs of full sentences.)
Recommendations
- [Suggested next steps for patient management including follow-up imaging, treatment plans, specialist referrals or further diagnostic testing] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list of bullet points.)
Report Prepared By
[Full name and designation of the clinician who prepared the report] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
Date of Report
[Date the report was prepared in DD/MM/YYYY format] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.)
