Abnormal Abdominal Ultrasound

The s10.ai USG Abdomen (Abnormal) template is expertly crafted for sonologists and radiologists to efficiently document abdominal ultrasound examinations. This comprehensive template includes sections for patient demographics, clinical indications, technical specifications, and detailed findings, ensuring thorough documentation of the pancreas, liver, gallbladder, kidneys, and spleen, with a focus on both normal and abnormal results. Radiologists seeking a structured format for reporting abnormal abdominal ultrasound findings will find this template invaluable for covering all critical aspects. Implement this template to enhance your ultrasound reporting workflow and uphold superior standards in clinical documentation.

3,462 uses

4.6/5.0

Aarav Patel

Template Structure

Organized sections for comprehensive clinical documentation

Abdominal Ultrasound

Patient Information:

Name: [Mention patient's name] (mention only if available)

Age & Gender: [Mention patient's age and gender] (mention only if available)

Date of Birth: [Mention patient's date of birth] (mention only if available)

Medical Record Number: [Mention patient's medical record number] (mention only if available)

Clinical Indication:

[Describe clinical indication] (describe the reason for the ultrasound examination, including any symptoms or medical history relevant to the scan)

Technical Information:

Date of Examination: [Date] (include the date the ultrasound was performed)

Sonographer: [Sonographer Name] (include the name of the sonographer or technician who performed the scan)

Equipment Used: [mention details of equipment and transducer used] (e.g., GE Logiq, curvilinear transducer operating at 2-5MHz)

Type of Examination: Abdominal Ultrasound

Findings:

(The below Findings sections contains sentences describing normal findings as defaults. Your task is to review each sentence and within each sentence review each normal finding to ensure that it is applicable for the patient based on the transcript and whenever/wherever needed edit the sentences based on the transcript to ensure that all abnormal findings are included)

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 [mention size of portal vein in mm] mm with normal flow.

The gallbladder is normal with a wall thickness of [mention thickness of gallbladder wall in mm] mm. No gallstones, polyps or sludge are seen within the lumen and the patient is sonographic Murphy’s negative. The CBD measures [mention size of common bile duct in mm] 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 [mention length and width of right kidney in cms (for e.g. 8 x 4)] cm and the left kidney measures [mention length and width of right kidney in cms (for e.g. 8 x 4)] cm.

The spleen is of normal size, shape and echotexture with a diameter of [mention size of spleen in cm] cm.

Impression:

[list each impression or diagnosis with brief description]

(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)

Sample Clinical Note

Example of completed documentation using this template

Ultrasound Abdomen
Patient Information:
Name: John Doe  
Age & Gender: 45, Male  
Date of Birth: 01/01/1978  
Medical Record Number: 123456  
Clinical Indication:
Patient reports 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 clearly visualized and appears normal in size, shape, and echotexture, with no ductal dilation.
The liver is normal in size, shape, and echotexture, with no intrahepatic duct dilation or focal lesions observed. 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 present within the lumen, and the patient is sonographic Murphy’s negative. The CBD measures 6 mm.
Both kidneys are normal in size and shape with smooth contours and normal cortical echotexture. The central echogenic complexes appear normal with no hydronephrosis. The right kidney measures 10 x 5 cm, and the left kidney measures 10 x 5 cm.
The spleen is normal in 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.

Clinical Benefits

Key advantages of using this template in clinical practice

The Ultrasound Abdomen clinical template is an essential tool for healthcare professionals seeking to streamline and enhance diagnostic accuracy in abdominal imaging. This comprehensive template includes key sections such as Patient Information, Clinical Indication, Technical Information, Findings, and Impression, ensuring a thorough and organized approach to documenting ultrasound results. With high-search healthcare keywords integrated, this template facilitates efficient data entry and retrieval, supporting clinicians in making informed decisions based on detailed imaging findings. By adopting this template, practitioners can improve workflow efficiency, enhance patient care, and ensure compliance with clinical documentation standards. Explore the Ultrasound Abdomen template today to optimize your diagnostic processes and elevate the quality of patient management.

Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.