Radiologist Template

USG Abdomen (Abnormal)

A professional Radiologist template for healthcare professionals.

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Specialty

Radiologist

Used

13 times

Type

Note

Last edited

8/21/2024

Created by

Siddharth Krishnakumar

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About this template

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.

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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.