abdomen and pelvic report template

Patient's history:
A 34 years old Chinese female patient came in for upper abdomen and pelvic ultrasound scan. She complained of abdominal pain at right lumbar region for two years before seeking medical attention. She has regular menses and has had no children before. LMP 9/8/2009

UPPER ABDOMEN

(1) Pancreas
The pancreas has a homogenous in echotexture. Head and body of the pancreas are seen. No evidence of mass or cystic structures in pancreatic head.

(2)Aorta:
The diameter of aorta measured was 1.65cm and no echogenic foci or plaque was detected.

(3)Liver:
Liver appeared homogeneous in echotexture with mid-clavicular measurement of 11.74cm.

(4)Gallbladder:
No abnormalities detected in the gallbladder.
The gallbladder wall thickness fall within normal range with measurement of 0.12cm. Bile duct is seen with no dilatation noted and measured 0.23cm.

(5) Kidneys
Bipolar length Right kidney: 8.81cm.
Bipolar length Left kidney: 9.32cm.
Both kidneys appeared normal in size and echotexture and their borders appeared normal and regular.

(6) Spleen
The size of spleen measured was 7.94cm. It had fine homogeneous echo-texture pattern.


LOWER ABDOMEN

Ultrasound Findings:
Uterus had homogenous echotexture with a well defined border. No mass or cystic structures were detected
She had an anteverted uterus with measurements:
Uterus length:6.16cm
Uterus height:2.10cm
Uterus width :6.03cm
Endometrium thickness: 0.91cm

Right ovary volume was 4.01cc
Left ovary volume was 6.86cc

Left ovary had a prominent follicle

No mass was found in right and left adnexa.

No evidence of hydronephrosis noted in left and right kidney.

INCIDENTAL FINDINGS
Colloid cyst with septations and two crystals with comet tail artifacts measuring 0.82 x 1.09 x 0.50 cm was found in right middle pole of thyroid gland. No vascularity was found within the cyst.