| Patient Name | Age / Sex | ||
|---|---|---|---|
| Referring Doctor | Date |
Indication: Routine abdominal sonography. Relevant clinical history and laboratory findings: Not supplied.
Technique: Real-time grayscale ultrasonography of the abdomen and pelvis performed using a curvilinear transducer. Targeted color Doppler assessment performed where clinically indicated. Examination performed with appropriate bladder filling, as feasible.
Liver: Liver is normal in size, shape and contour, with smooth capsular outline and homogeneous parenchymal echotexture. Hepatic echogenicity is within normal limits. No focal solid or cystic hepatic lesion is identified. No intrahepatic collection is seen. Right lobe span in midclavicular line: 140 mm; left lobe: 75 mm; caudate lobe: 25 mm.
Intrahepatic Biliary Radicles / Hepatic Ducts: Intrahepatic biliary radicles are not dilated. Visualized right and left hepatic ducts show no abnormal dilatation.
Portal Vein: Main portal vein is normal in caliber and course, with patent lumen. Hepatopetal flow is demonstrated on color Doppler when assessed. No visible portal venous thrombus. Portal vein diameter: 11 mm.
Gallbladder: Gallbladder is adequately distended with normal contour. Wall thickness is within normal limits. No echogenic calculus, sludge, intraluminal mass or polyp is seen. No pericholecystic collection is identified. Gallbladder wall thickness: 2 mm. Sonographic Murphy sign: negative (example).
Common Bile Duct (CBD): Visualized CBD is normal in caliber without evident intraluminal calculus or biliary obstruction. CBD diameter: 4 mm.
Pancreas: Visualized head, body and tail of the pancreas are normal in size, outline and echotexture. No definite focal lesion, pancreatic duct dilatation or peripancreatic fluid collection is seen. Main pancreatic duct: 2 mm (illustrative).
Spleen: Spleen is normal in size and shape with homogeneous echotexture and smooth outline. No focal splenic lesion or perisplenic collection is detected. Splenic bipolar length: 105 mm.
Inferior Vena Cava (IVC): Visualized IVC is patent and normal in caliber. No definite intraluminal thrombus is seen. Respiratory caliber variation is present when assessed.
Abdominal Aorta: Visualized abdominal aorta is normal in course and caliber, without aneurysmal dilatation. Maximum visualized aortic diameter: 18 mm.
Right Kidney: Right kidney is normally located and shows normal size, contour and renal parenchymal echogenicity. Cortical thickness and corticomedullary differentiation are maintained. No renal calculus, focal mass, cyst or hydronephrosis is identified. Size: 105 × 48 mm; cortical thickness: 8 mm.
Left Kidney: Left kidney is normally located and shows normal size, contour and renal parenchymal echogenicity. Cortical thickness and corticomedullary differentiation are maintained. No renal calculus, focal mass, cyst or hydronephrosis is identified. Size: 108 × 50 mm; cortical thickness: 8 mm.
Urinary Bladder: Urinary bladder is adequately distended with smooth, regular walls and anechoic contents.
Uterus: Uterus is normal in size (95 x 55 x 45 mm), shape and configuration with smooth outline and homogeneous myometrial echotexture. No definite focal myometrial lesion is identified. Endometrial echo is central and regular, with normal thickness for the menstrual phase.
Right Ovary: Right ovary is normal in size, shape and configuration with smooth outline and homogeneous stromal echotexture. Normal ovarian follicles are visualized. No definite solid or cystic adnexal lesion is identified. No abnormal ovarian enlargement is seen.
Left Ovary: Left ovary is normal in size, shape and configuration with smooth outline and homogeneous stromal echotexture. Normal ovarian follicles are visualized. No definite solid or cystic adnexal lesion is identified. No abnormal ovarian enlargement is seen.
Bowel Loops: Visualized bowel loops are not abnormally dilated. No obvious segmental bowel wall thickening or localized fluid collection is identified on this routine survey. Bowel gas may limit assessment.
Peritoneal Cavity / Pelvis: No free intraperitoneal fluid, ascites or obvious localized collection is seen in the visualized abdomen or pelvis.
Retroperitoneum / Lymph Nodes: No obvious enlarged retroperitoneal lymph nodes or mass is seen in the accessible regions. Evaluation may be limited by bowel gas.
Additional Findings: _____.
No significant sonographic abnormality detected in the visualized abdominal and pelvic organs, including the uterus and bilateral ovaries, subject to completion and confirmation of all findings above.
Correlate with clinical findings, menstrual history and relevant laboratory investigations. Further gynecological evaluation, transvaginal ultrasonography or other targeted imaging may be considered when clinically indicated.
Ultrasound is operator-dependent. Bowel gas, body habitus, patient preparation and bladder distension may limit evaluation of some structures. The pancreas, retroperitoneum, ureters, bowel, uterus, endometrium and ovaries may not be completely assessed by routine transabdominal ultrasonography. Small uterine or adnexal lesions and subtle endometrial abnormalities may require transvaginal ultrasonography for further evaluation when clinically appropriate. Measurements and statements should be verified against the actual scan before finalizing the report.
Kindly report any typographical errors and submit for correction within 7 days. This report and accompanying images are not valid for medico-legal purposes.
MBBS MD (Consultant Radiologist)