**Scan date:**
01 2024
**Clinical information:**
- Persistent right upper quadrant pain for 3 weeks
- Nausea and occasional vomiting
- Elevated liver enzymes
**Patient information:**
- Jane Doe, ID: JD7890, DOB: 01/05/1975
- Referring physician: Dr. Emily White
- Date of examination: 01 November 2024
- Type of study with details such as imaging modality used, anatomical part of body studied, side of body studied: Abdominal Ultrasound, right upper quadrant
**Clinical history:**
- Patient presenting with acute onset right upper quadrant pain, radiating to the back. Associated symptoms include nausea, loss of appetite, and a low-grade fever. Suspected cholecystitis.
**Comparison:**
- No prior imaging studies available for comparison.
**Technique:**
- Transabdominal ultrasound performed with a 3.5 MHz curvilinear probe. Real-time imaging obtained in supine and left lateral decubitus positions. Colour Doppler imaging applied to assess vascularity.
**Findings:**
- Liver: Normal in size and echotexture. No focal lesions identified. Hepatic vasculature appears patent.
- Gallbladder: Distended, measuring 9 cm x 4 cm. Wall is thickened, measuring 5 mm, with pericholecystic fluid noted. Multiple calculi are present, the largest measuring 1.5 cm, consistent with cholelithiasis. Murphy's sign is positive on sonographic palpation.
- Bile Ducts: Common bile duct measures 4 mm, within normal limits. No intrahepatic biliary dilatation.
- Pancreas: Visualised head, body, and tail appear unremarkable. No peripancreatic fluid collection.
- Kidneys: Right kidney is normal in size and echotexture. No hydronephrosis or calculi.
- Spleen: Not fully visualised, but the visible portion appears normal.
- Normal findings: Aorta and Inferior Vena Cava are normal in calibre and course. No ascites.
**Impression:**
- Acute cholecystitis with cholelithiasis.
**Recommendations for follow-up studies, further imaging, or clinical management based on imaging findings:**
- Recommend surgical consultation for cholecystectomy.
- Recommend blood tests to monitor inflammatory markers and liver function.
**Additional notes:**
- Limitations of study or factors affecting interpretation: Bowel gas partially obscured visualisation of the posterior aspect of the pancreas.
- Comments on quality of study or any technical issues encountered: Good quality images obtained despite patient discomfort during probe pressure over the right upper quadrant.
