Ultrasound 📝 Report structure
SCRS
Abdominal Ultrasound Report
Patient & Exam Details
Patient
John
ID / Age / Sex
123456 · 34 y · M
Indication
RUQ pain, abnormal LFTs
Technique
Convex 3.5–5 MHz; longitudinal & transverse planes; color Doppler of portal vein.
Comparison
No prior available
Findings
- Liver: Normal size (14.0 cm MCL). Homogeneous echotexture. No focal lesion identified.
- Gallbladder: Well distended. Single echogenic focus 6 mm with posterior acoustic shadowing — consistent with calculus. No wall thickening or pericholecystic fluid.
- Pancreas: Visualized portion appears unremarkable. Study limited by bowel gas.
- Spleen: Normal size and texture; measures 11.2 cm.
- Kidneys: Right kidney 10.8 cm, left kidney 11.0 cm. No hydronephrosis.
- Ascites: No free fluid identified.
Measurements
Liver (MCL): 14.0 cm · Spleen length: 11.2 cm · Right kidney: 10.8 cm · Gallstone: 6 mm
Impression
- Cholelithiasis — single 6 mm gallstone within gallbladder.
- No sonographic evidence of acute cholecystitis (no wall thickening or pericholecystic fluid).
- Liver and spleen dimensions within expected limits; no focal hepatic lesion detected.
Recommendations & Limitations
Recommendation
Correlate with LFTs. Consider surgical referral if symptomatic.
Limitations
Pancreas partially obscured by bowel gas; full pancreatic evaluation limited.
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