OVERVIEW
This page is dedicated to providing an example of a radiology report for an unremarkable transabdominal abdominal ultrasound study (conducted transabdominally). Read more about how to interpret this study here. For examples of unremarkable studies look here.
*Please keep in mind that this is just one example of how a radiology report can web written. Personal/institutional practices may vary depending on the context of where the report is generated
REPORT EXAMPLE:
RESPONSIBLE INTERPRETER:
Mr. Stepwards
EXAMINATION:
US Abdomen Complete
CLINICAL INDICATION:
Right upper quadrant pain and nausea (one example, there can be many others)
TECHNIQUE:
Transabodminal sonography of the abdomen (complete).
COMPARISON:
No prior studies available for comparison (if there are, list the study type and date)
LIMITATIONS:
The study was technically limited secondary to…(bowel gas, body habitus, etc. or state it was not limited if that is the case).
FINDINGS:
LIVER:
Unremarkable
INTRAHEPATIC DUCTS:
Unremarkable
EXTRAHEPATIC DUCTS:
Unremarkable. Common duct diameter: X.X cm
GALLBLADDER:
Unremarkable
PANCREAS:
Imaged portion unremarkable. The distal pancreas is not visualized (comment on it if it is)
SPLEEN:
Unremarkable. Measures X.X cm in length.
RIGHT KIDNEY:
Unremarkable. Measures X.X cm in length.
LEFT KIDNEY:
Unremarkable. Measures X.X cm in length.
AORTA:
Imaged portion unremarkable.
INFERIOR VENA CAVA:
Imaged portion unremarkable.
OTHER:
No free fluid
IMPRESSION
Unremarkable abdominal ultrasound with no abnormal findings.
*I, the attending physician, attest that I have performed and/or supervised the resident for the key and critical components of this procedure. I have personally reviewed the images pertinent to this examination and agree with the interpretation. (Statements like this may or not be included depending upon the clinical context)
Page Updated: 08.08.2017