Normal Abdominal Ultrasound Report Template (Complete / RUQ)

Normal complete abdominal ultrasound report template: liver, gallbladder, CBD with measurement, pancreas, kidneys, aorta — plus RUQ-only wording.

EXAMINATION: Complete abdominal ultrasound.

CLINICAL HISTORY: [indication]

COMPARISON: None available.

TECHNIQUE: Real-time grayscale and color Doppler imaging of the abdomen.

FINDINGS:
Liver: Normal size and echotexture. No focal lesion. Hepatopetal flow in
the main portal vein.
Gallbladder: No cholelithiasis. No wall thickening or pericholecystic
fluid. Negative sonographic Murphy sign.
Common bile duct: Normal caliber, measuring [x] mm.
Pancreas: Visualized portions unremarkable.
Spleen: Normal size.
Kidneys: Right kidney [x] cm; left kidney [x] cm. Normal echogenicity and
cortical thickness. No hydronephrosis or calculus.
Aorta: Normal caliber of the visualized abdominal aorta.
Ascites: None.

IMPRESSION:
1. Normal abdominal ultrasound.

Dictation notes

• Measure the CBD on every study and state the number — it anchors a later comparison when the patient returns with pain.
• For a limited RUQ study, retitle the exam and drop the organs not examined rather than reporting them as normal.

Related references

SRU gallbladder polyp calculator

Frequently asked questions

What does a complete abdominal ultrasound report include?

A complete abdominal ultrasound report covers the liver (size, echotexture, focal lesions, portal vein flow direction), gallbladder (stones, wall thickening, pericholecystic fluid, sonographic Murphy sign), the common bile duct with a measurement, the visualized pancreas, spleen size, both kidneys with lengths, the abdominal aorta, and the presence or absence of ascites. The normal impression is 'Normal abdominal ultrasound.'

Why should the common bile duct be measured on every ultrasound?

Stating the CBD caliber as a number — not just 'normal' — anchors every later comparison when the patient returns with pain or abnormal liver tests. Ductal dilation is often judged by change as much as by absolute threshold, and the threshold itself varies with age and prior cholecystectomy. A documented baseline measurement turns a borderline future value into an answerable question.

How should a limited right upper quadrant ultrasound be reported?

A limited RUQ study should be retitled as such, and the report should include only the organs actually examined rather than reporting unexamined organs as normal. Describing the pancreas or pelvis as unremarkable when they were never scanned creates a false record and a liability exposure. The examination title, technique statement and findings must agree about the scope of the study.

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