Abdominal sonography US report sample

ULTRASOUND REPORT – UPPER ABDOMEN

Patient Name: [--]

Age/Sex: -- Years / Male

Referring Physician: Dr. [--]

Examination Date: [18-July-2025]


[Sonography of the upper Abdomen]
Real time B-mode ultrasonography of abdomen done.
Rout: Trans abdominal.
Findings
Liver:
  • Size: Normal / Enlarged – [___ cm in midclavicular line]
  • Contour: Smooth / Irregular
  • Echotexture: Homogeneous / Coarse / Hyperechoic (Fatty infiltration)
  • Focal Lesions: None / [Specify cyst, hemangioma, etc.]
  • Intrahepatic Biliary Ducts: Not dilated
  • Portal Vein: Normal in diameter and flow
  • Gall bladder:
  • Shape & Wall: Normal / Thickened / Distended
  • Lumen Contents: Anechoic / Sludge / Calculi (size ___ mm)
  • Murphy’s Sign: Negative / Positive (if clinically relevant)
  • Biliary Tree:
  • Common Bile Duct (CBD): Normal / Dilated – [___ mm]
  • No evidence of obstruction or stones in biliary tree
  • Pancreas:Normal in size and echotexture. No focal mass or calcification. Main pancreatic duct not dilated.
    Spleen:
  • Size: Normal – [___ cm craniocaudal length]
  • Parenchyma: Homogeneous echotexture
  • No focal lesions or splenomegaly
  • Right kidney:Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, Parenchymal thickness and echo texture within normal limit. No back pressure or hydronephrosis is note. No masses, cyst or stone is seen.
    Left kidney:Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, Parenchymal thickness and echo texture within normal limit. No back pressure or hydronephrosis is note. No masses, cyst or stone is seen.
    Abdominal aorta:
  • Caliber: Normal – [___ mm]
  • No aneurysmal dilatation or mural thrombus noted


  • Impression:

    • Normal ultrasound examination of the abdomen with no significant findings.

    ULTRASOUND REPORT – UPPER ABDOMEN

    Patient Name: [--]

    Age/Sex: -- Years / Female

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Sonography of the upper Abdomen]
    Real time B-mode ultrasonography of abdomen done.
    Rout: Trans abdominal.
    Findings
    Liver:
  • Size: Normal / Enlarged – [___ cm in midclavicular line]
  • Contour: Smooth / Irregular
  • Echotexture: Homogeneous / Coarse / Hyperechoic (Fatty infiltration)
  • Focal Lesions: None / [Specify cyst, hemangioma, etc.]
  • Intrahepatic Biliary Ducts: Not dilated
  • Portal Vein: Normal in diameter and flow
  • Gall bladder:
  • Shape & Wall: Normal / Thickened / Distended
  • Lumen Contents: Anechoic / Sludge / Calculi (size ___ mm)
  • Murphy’s Sign: Negative / Positive (if clinically relevant)
  • Biliary Tree:
  • Common Bile Duct (CBD): Normal / Dilated – [___ mm]
  • No evidence of obstruction or stones in biliary tree
  • Pancreas:Normal in size and echotexture. No focal mass or calcification. Main pancreatic duct not dilated.
    Spleen:
  • Size: Normal – [___ cm craniocaudal length]
  • Parenchyma: Homogeneous echotexture
  • No focal lesions or splenomegaly
  • Right kidney:Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, Parenchymal thickness and echo texture within normal limit. No back pressure or hydronephrosis is note. No masses, cyst or stone is seen.
    Left kidney:Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, Parenchymal thickness and echo texture within normal limit. No back pressure or hydronephrosis is note. No masses, cyst or stone is seen.
    Abdominal aorta:
  • Caliber: Normal – [___ mm]
  • No aneurysmal dilatation or mural thrombus noted


  • Impression:

    • Normal ultrasound examination of the abdomen with no significant findings.

    ULTRASOUND REPORT – ABDOMEN & PELVIS

    Patient Name: [--]

    Age/Sex: -- Years / Male

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Sonography of the Abdomen and Pelvis]
    Real-time B-mode ultrasonography of the upper abdomen and pelvis was performed.
    Route: Transabdominal.
    Findings
    Liver:
  • Size: Normal / Enlarged – [___ cm in midclavicular line]
  • Contour: Smooth / Irregular
  • Echotexture: Homogeneous / Coarse / Hyperechoic (Fatty infiltration)
  • Focal Lesions: None / [Specify cyst, hemangioma, etc.]
  • Intrahepatic Biliary Ducts: Not dilated
  • Portal Vein: Normal in diameter and flow
  • Gall Bladder:
  • Shape & Wall: Normal / Thickened / Distended
  • Lumen Contents: Anechoic / Sludge / Calculi (size ___ mm)
  • Murphy’s Sign: Negative / Positive
  • Biliary Tree:
  • Common Bile Duct (CBD): Normal / Dilated – [___ mm]
  • No evidence of obstruction or stones in biliary tree
  • Pancreas: Normal in size and echotexture. No focal mass or calcification. Main pancreatic duct not dilated.

    Spleen:
  • Size: Normal – [___ cm craniocaudal length]
  • Parenchyma: Homogeneous echotexture
  • No focal lesions or splenomegaly
  • Right Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Left Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Abdominal Aorta:
  • Caliber: Normal – [___ mm]
  • No aneurysmal dilatation or mural thrombus noted
  • Urinary Bladder:
  • Wall: Normal thickness
  • Lumen: Anechoic. No calculi or masses seen
  • Post-void residual: [___ ml], if assessed
  • Prostate:
  • Size: [___ x ___ x ___ mm]; Approx. Volume: [___ cc]
  • Shape and Echotexture: Normal / Mildly enlarged / Heterogeneous
  • No focal lesions or calcifications

  • Impression:

    • Normal sonographic study of the abdomen and pelvis.

    ULTRASOUND REPORT – ABDOMEN & PELVIS

    Patient Name: [--]

    Age/Sex: -- Years / Female

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Sonography of the Abdomen and Pelvis]
    Real-time B-mode ultrasonography of the upper abdomen and pelvis was performed.
    Route: Transabdominal.
    Findings
    Liver:
  • Size: Normal / Enlarged – [___ cm in midclavicular line]
  • Contour: Smooth / Irregular
  • Echotexture: Homogeneous / Coarse / Hyperechoic (Fatty infiltration)
  • Focal Lesions: None / [Specify cyst, hemangioma, etc.]
  • Intrahepatic Biliary Ducts: Not dilated
  • Portal Vein: Normal in diameter and flow
  • Gall Bladder:
  • Shape & Wall: Normal / Thickened / Distended
  • Lumen Contents: Anechoic / Sludge / Calculi (size ___ mm)
  • Murphy’s Sign: Negative / Positive
  • Biliary Tree:
  • Common Bile Duct (CBD): Normal / Dilated – [___ mm]
  • No evidence of obstruction or stones in biliary tree
  • Pancreas: Normal in size and echotexture. No focal mass or calcification. Main pancreatic duct not dilated.

    Spleen:
  • Size: Normal – [___ cm craniocaudal length]
  • Parenchyma: Homogeneous echotexture
  • No focal lesions or splenomegaly
  • Right Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Left Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Abdominal Aorta:
  • Caliber: Normal – [___ mm]
  • No aneurysmal dilatation or mural thrombus noted
  • Urinary Bladder:
  • Wall: Normal thickness
  • Lumen: Anechoic. No calculi or masses seen
  • Post-void residual: [___ ml], if assessed
  • Uterus:The uterus is normal in size and shape, measuring [--x--x-- mm]. The endometrial lining normal. Myometrial thickness within normal limit. No fibroids or masses are identified.
    Ovaries:
  • Right Ovary: [___ x ___ mm]; Normal volume; No cysts/masses
  • Left Ovary: [___ x ___ mm]; Normal volume; No cysts/masses
  • No adnexal masses or free fluid in pouch of Douglas

  • Impression:

    • Normal sonographic study of the abdomen and pelvis.

    ULTRASOUND REPORT – KUB (Kidneys, Ureters, Bladder)

    Patient Name: [--]

    Age/Sex: -- Years / Male

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Sonography of the KUB Region]
    Real-time B-mode ultrasonography of the kidneys, ureters, and urinary bladder was performed.
    Route: Transabdominal.
    Findings
    Right Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Left Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Ureters:
  • Visualized segments are not dilated
  • No evidence of obstruction or calculi
  • Urinary Bladder:
  • Wall: Normal thickness (~3 mm when full)
  • Lumen: Anechoic, no internal echoes or masses
  • Post-void residual urine: [___ ml], if assessed
  • Prostate:
  • Size: [___ x ___ x ___ mm]; Approx. Volume: [___ cc]
  • Echotexture: Normal / Mildly enlarged / Heterogeneous
  • No focal lesions or calcifications

  • Impression:

    • Normal sonographic study of the kidneys, ureters, bladder, and prostate.

    ULTRASOUND REPORT – KUB (Kidneys, Ureters, Bladder)

    Patient Name: [--]

    Age/Sex: -- Years / Female

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Sonography of the KUB Region]
    Real-time B-mode ultrasonography of the kidneys, ureters, and urinary bladder was performed.
    Route: Transabdominal.
    Findings
    Right Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Left Kidney: Position & Size: Normal – [--x--x-- mm]. Well maintained CMD, parenchymal thickness and echo texture within normal limits. No back pressure or hydronephrosis noted. No masses, cysts, or stones seen.
    Ureters:
  • Visualized segments are not dilated
  • No evidence of obstruction or calculi
  • Urinary Bladder:
  • Wall: Normal thickness (~3 mm when full)
  • Lumen: Anechoic, no internal echoes or masses
  • Post-void residual urine: [___ ml], if assessed
  • Uterus/Ovaries (if visualized):
  • Uterus: [Normal / Bulky / Retroverted / Anteverted], Size: [___ x ___ x ___ cm]
  • Ovaries: [Normal / Not well visualized]; Follicles noted if applicable

  • Impression:

    • Normal sonographic study of the kidneys, ureters, and urinary bladder.

    ULTRASOUND REPORT – MALE LOWER ABDOMEN (Pelvis)

    Patient Name: [--]

    Age/Sex: -- Years / Male

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Sonography of the Pelvic / Lower Abdominal Region]
    Real-time transabdominal ultrasonography of the lower abdomen and pelvic organs was performed.
    Route: Transabdominal (with full bladder technique).
    Findings
    Urinary Bladder:
  • Wall: Uniform and regular, thickness ~3 mm when full
  • Lumen: Anechoic, no internal echoes or masses
  • Post-void residual urine: [___ ml], if assessed
  • Prostate Gland:
  • Size: [___ x ___ x ___ cm]; Volume: [__] cc
  • Echotexture: Homogeneous / Mildly heterogeneous
  • No focal lesions or calcifications
  • Median lobe: Not prominent / Prominent (if any)
  • Seminal Vesicles:
  • Visualized and appear normal in size and echotexture
  • No evidence of cysts or dilatation
  • Pelvic Peritoneal Cavity:
  • No free fluid or abnormal mass lesion seen


  • Impression:

    • Normal sonographic evaluation of the urinary bladder, prostate, and seminal vesicles.

    ULTRASOUND REPORT – FEMALE LOWER ABDOMEN (Pelvis)

    Patient Name: [--]

    Age/Sex: -- Years / Female

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Sonography of the Pelvic / Lower Abdominal Region]
    Real-time transabdominal ultrasonography of the lower abdomen and pelvic organs was performed.
    Route: Transabdominal (with full bladder technique).
    Findings

    Urinary Bladder:
  • Wall: Uniform and regular, thickness ~3 mm when full
  • Lumen: Anechoic, no internal echoes or masses
  • Post-void residual urine: [___ ml], if assessed
  • Uterus:The uterus is normal in size and shape, measuring [80x50x40mm-]. The endometrial lining normal. Myometrial thickness within normal limit. No fibroids or masses are identified.
    Ovaries:
  • Right Ovary: [___ x ___ x ___ cm], volume: [__] cc
  • Left Ovary: [___ x ___ x ___ cm], volume: [__] cc
  • Follicular activity present / No cysts / Functional cyst noted
  • Adnexa:
  • No adnexal mass or collection visualized

  • Pouch of Douglas (POD):
  • No free fluid seen


  • Impression:

    • Normal sonographic appearance of uterus, ovaries, and urinary bladder.

    ULTRASOUND REPORT – MALE FAST SCAN

    Patient Name: [--]

    Age/Sex: -- Years / Male

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Focused Assessment with Sonography for Trauma (FAST)]
    Focused bedside ultrasound examination was performed to assess potential internal bleeding in trauma settings. Views included subxiphoid cardiac, perihepatic (Morison’s pouch), perisplenic, pelvis (pouch of Douglas / rectovesical pouch), and bilateral pleural spaces.
    Findings
    Pericardial View:
  • Subxiphoid view shows no pericardial effusion
  • Right Upper Quadrant (Morison’s Pouch):
  • Liver and right kidney interface shows no free fluid
  • Left Upper Quadrant (Splenorenal):
  • Spleen and left kidney interface shows no free fluid
  • Pelvic View (Rectovesical Pouch):
  • No free fluid noted in the rectovesical pouch
  • Bilateral Pleural Views:
  • No evidence of hemothorax or pleural effusion
  • Urinary Bladder:
  • Well-distended; walls regular and uniform; no internal echoes

  • Impression:

    • No sonographic evidence of free fluid in peritoneal, pelvic, pericardial, or pleural cavities.
    • FAST scan appears negative for internal hemorrhage.

    ULTRASOUND REPORT – FEMALE FAST SCAN

    Patient Name: [--]

    Age/Sex: -- Years / Female

    Referring Physician: Dr. [--]

    Examination Date: [18-July-2025]


    [Focused Assessment with Sonography for Trauma (FAST)]

    Focused bedside ultrasound examination was performed to assess potential internal bleeding in trauma settings. Views included subxiphoid cardiac, perihepatic (Morison’s pouch), perisplenic, pelvis (pouch of Douglas), and bilateral pleural spaces.
    Findings
    Pericardial View:
  • Subxiphoid view shows no pericardial effusion
  • Right Upper Quadrant (Morison’s Pouch):
  • Liver and right kidney interface shows no free fluid
  • Left Upper Quadrant (Splenorenal):
  • Spleen and left kidney interface shows no free fluid
  • Pelvic View (Pouch of Douglas):
  • No free fluid noted in the pouch of Douglas
  • Bilateral Pleural Views:
  • No evidence of hemothorax or pleural effusion
  • Urinary Bladder:
  • Well-distended; walls regular and uniform; no internal echoes

  • Impression:

    • No sonographic evidence of free fluid in peritoneal, pelvic, pericardial, or pleural cavities.
    • FAST scan appears negative for internal hemorrhage.

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