REPORT WRITING IN

ULTRASOUND
BY
DR. JEROME NJOKU (Ph.D)

10/15/2020 DR. J.C. NJOKU 1

• Means of communicating the findings of the
examination to the referring clinician.
• A sonographer must be held accountable for his
report.
• It can make or mar proper patient’s
management.
• Sonographer should be aware at all times of the
implications for the patient of the contents of
the report.
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• Medico-legal Aspects:
• part of the permanent record held in the patient’s notes and
thus is of medicolegal importance as well as essential for
influencing patient management.
– Personnel qualification
– Annual license
– Patient identity: name, age, sex, number etc.
– Date of examination
– Name and signature of personnel
– Ideally, all reports should attempt to answer the original clinical
question.

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• Correction fluid or sticky labels should not be
used to cover errors.
• Any error that is made should have a single
horizontal line through the words or sentence
and initialed.
• If error correction has defaced a report it is
advisable to retype it.

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• Where appropriate, state challenges/hindrances to
optimum scanning or accurate diagnosis eg bowel
gas, postprandial gall bladder, patient’s inability to
achieve full bladder, without being non-committal.
• The sonographer should be aware of his/her
limitations and consequently seek clinical
advice/second opinion when necessary.
• None-availability of proper equipment not an excuse.
When handicapped, refer, seek second opinion.

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 Guidelines for reporting
• No single “correct” way to report but must be,
clear, concise, precise, logical structure, relevant,
timely and an attempt to answer the clinical
question, with differential diagnoses if appropriate,
and suggestions for further management.
• Must contain facility’s name, patient’s details,
sonographers name and signature, and date of
investigation.
• May be descriptive, without necessarily drawing
conclusions.
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• Standard reports which are understood and
accepted by staff within a hospital may need to be
modified for outside referrals.
• Potentially ambiguous phraseology should not be
used.
• Short paragraphs should be used and the burying
of important comments avoided.
• Abnormal and related findings should be grouped
• Irrelevant information should be avoided.
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• Provided they address the clinical questions,
conclusions or impressions are preferred by
most referring clinicians.
• Report templates can be designed locally in
collaboration with referring clinicians to ensure
that the required information is given
consistently and in a clear and concise manner.
• When constructing the report it is preferable to
write in the present tense.
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• Images provided are only representative of, and usually
vastly inferior to, the dynamic scan obtained at the time of
the examination.
• Referring clinicians rely on the report rather than the
images, and therefore, every care should be taken to
optimise the report.
• Stored images necessary to provide valuable back-up,
demonstrate the technique and settings used at the time
of the examination, may be used as evidence in
medicolegal cases, and are helpful to refer to for
comparison at follow-up appointments.
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• Style of writing is personal but all the essentials must
be included.
• Abbreviations should only be used when the user is
confident that they will be clearly interpreted
• Learn to convey much information in fewer words eg
“a live intra-uterine foetal pole, coexisting with a thick-
walled right ovarian cyst”.
• You may only need to summarise a report if it has
become too lengthy and probably laden with many
non-essentials.
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 Guidelines cont’d
• Report should include size, shape, location,
echogenicity and echo texture of organs/lesions.
• Not only statistics. Add a statement indicating
whether or not measurement lies within normal
limits.
• Can be hand-written or typed, but must include
name and signature of the sonographer.
• May include suggestions for other tests e.g. x-ray,
CT, Lab. etc- for further evaluation.
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• When scan is for broad a body part such as
abdomen, emphasis of report should focus on
referenced organ and or incidentally diseased
organ.
• Start reporting from referenced organ
followed by incidentally diseased organ.
• Report should describe ultrasound findings,
not clinical findings/suspicions.

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• A report may raise a query (provided not same
query raised by referring clinician) or rule out a
condition/disease.
• “Queries/rule out” may come after detailed
descriptions of findings and may obviate the
need for drawing conclusions.
• When described features are consistent with or
suggestive of a known condition/disease, please
say so.
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 Guidelines cont’d
• Clinical findings and patient’s response to
questions may assist the Sonographer in the
examination and reporting e.g. LMP, history of
fall, itching, vaginal discharge and colour,
previous infection and treatment, etc.
• Good knowledge of normal organ locations,
dimensions and physiology is important for
accurate diagnosis and reporting.

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 Guidelines cont’d
• Report may be complemented with well-
labeled images or drawings.
• Clinical history and provisional diagnosis may
help in deciding where and what to look for.
• It is important to understand the strength and
limitations of ultrasound in order to avoid
false claims. Avoid sweeping statements eg.
• It helps to palpate a lump before scanning.

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 Guidelines cont’d
• In most cases of breast pain and nipple
discharge, scan result may be negative.
• Ask questions regarding every incision seen on
patient’s body as this may help when some
organs are not found.
• Report should be tailored to the request.
• If differential diagnosis is offered, the most
likely diagnosis must come first.

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 Caution
• Inexperience, wrong choice of probe and
wrong technique may produce false positive or
false negative results.
• Some lesions may be isoechoic or subtle. When
in doubt ask for second opinion or refer to a
superior officer.
• Remember that the scan result may lead to a
radical change in the management of a patient.

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 Caution cont’d
• False positive/negative reports that have
immediate consequences may lead to litigations.
• Take cognizance of the limitations of ultrasound
e.g. inability to differentiate between benign
and malignant lesions.
• Don’t comment on structures not seen.
• Maintain a register of all reports. See your
previous report to avoid contradictions.

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• State technique used eg. TAS, TVS or both,
erect/supine, manoeavres adopted etc.
• Was TVS done with pt consent? Any
chaperon?
• Suggest if follow-up scans needed and when.

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 OBSTETRIC REPORTING
• Content of report will depend on age of pregnancy.
• State: number of foetuses, viability, presentation, lie,
heart rate.
• Placenta- location, size, maturity.
• Amniotic fluid- adequate or polyhydramnios or
oligohydramnios.
• Dating – indicate age based on measured
parameters.
• Cervix- cervical length and internal os diameter-
better done with transvaginal probe.
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 OBSTETRIC REPORTING
• Any coexisting fibroids or cysts?
• Any foetal abnormality?
• Check if foetal growth is normal or retarded.
• Differentiate between symmetrical and
asymmetrical intra-uterine growth retardation
(IUGR).
• First trimester report may be very concise.
• Observe for blighted ovum/anembryonic,
IUFD/missed abortion, incomplete abortion.
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 OBSTETRIC REPORTING CONT’D
• In very early pregnancy when foetal cardiac
activity may not be apparent report may not be
conclusive unless transvaginal probe is used.
• The report may therefore require the patient to
repeat the scan in two weeks time to ascertain
viability.
• Note: Some Depts. may use proforma report
sheets. Discuss.

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• Develop scanning protocols for different
conditions.
• A report concluding with significant anomaly
or IUFD must first of all describe the relevant
features.

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 Gynaecology Reporting
• Uterus- length, A-P diameter, width, orientation.
Decide whether bulky, normal, small sized or absent.
• Be mindful of typical sizes for different ages and
parity.
• If fibroids exist indicate number, size, location, echo
texture, effect on endometrium, upper vagina.
• If an IUCD is seen indicate whether properly located
or not.

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 Gynaecology cont’d
• Endometrium- thickness, regularity, fluid, gas.
• Ovaries- size, echo texture, presence/absence of
cysts/solid mass. Were ovaries seen or not.
• Adnexae- presence/absence of solid/cystic
mass/free or loculated fluid, adnexal ring.
• Note that a normal fallopian tube cannot be seen
even with transvaginal probe.
• Cul-de-sac: Any mass or significant fluid
collection/gas?
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• Describing a dominant follicle in the ovary as a
‘cyst’ may often be the source of needless
repeat scans and patient anxiety.
• If the ovary has normal physiological features,
it should be called normal.
• The term ‘cyst’ is often understood to imply a
pathological finding by referring clinicians.

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 Follicular tracking
• Should be a composite report of all 3-4 scans
which may have commenced on day 9 of the
onset of the last menstruation.
• The size of the leading follicle as it changed
with each scan is indicated.
• State whether or not ovulation is deemed to
have occurred.

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 Abdomen
• Liver- size, echo texture, presence/absence of
cystic/solid/complex mass/abscess, margins
and borders. Use segmentation.
• Gall bladder- size, structure, wall thickness,
presence/absence of stone/sludge, masses or
polyps, biliary ducts, size of common bile duct,
Murphy’s sign.

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 Abdomen-kidneys
• Kidneys- size, shape, location, movement with
breathing, echo texture, echogenicity.
• Presence/absence of stones, calyceal
dilatation, hydronephrosis, solid/cystic masses
and their size and location.
• Check borders for laceration, bleed, urinoma.
• Note: a normal ureter cannot be seen with
ultrasound.

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 Abdomen cont’d
• Spleen- size, echo texture, presence/absence
of solid/cystic/complex mass, borders in case
of injury.
• Pancreas- size of head, neck, body, tail. Echo
texture, size of ducts. Presence/absence of
mass, calcifications, contour, pseudocysts.
• Supra-renal gland- size, shape, presence or
absence of mass.

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 Abdomen cont’d
• Abdominal aorta and inferior vena cava- size of
vessel (diameter measured in-to-in on a cross
sectional image), observe for para-aortic
lymph-adenopathy, periportal lymph-
adenopathy, aneurism.
• Ascites and haemoperitonium- free fluid in
Morrison’s pouch, lesser sac, greater sac, para-
colic gutters, anterior and posterior cul-de-sac.

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 Abdomen cont’d
• Note: ultrasound cannot diagnose gastric or
duodenal ulcers except in case of ruptured
viscus leading to peritonitis-emergency.
• Intra-abdominal masses- origin, intestinal
obstruction, gas/fluid dilation of bowl
segments, right iliac fossa complex mass/fluid
collection, inflamed or ruptured appendix,
tenderness in RIF .

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 Abdomen cont’d
• Abdominal wall (high frequency probe)- any breach
of the linear alba leading to hernia, measure width
of breach. Check for peristalsis, presence of
omentum.
• Lipoma/fibroma- swelling in the subcutaneous
layer, solid homogeneous hypo/hyper echoic mass.
• Abscess formation- complex or homogeneous thick
irregular walled mass on psoas muscle, qaudratus
lumborum or rectus abdominis muslce.

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 Pelvis
• Urinary bladder- Bladder wall thickness and
contour, presence/absence of echoes in urine
e.g haematuria, calculus, cystitis.
• Any supra-pubic or inguinal mass -
solid/cystic/complex.
• Prostate- measure length, A-P diameter and
width and calculate volume, decide whether
normal or enlarged.

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 Pelvis cont’d
• Prostate- Check prostate parenchyma for mass,
integrity of capsule, asses zones for
enlargement- median zone enlargement may
indicate benign prostatic enlargement, while
most ca prostate originate in the peripheral
zone.
• Calculate residual urine in cases of prostate
problems, urinary tract infections and
neurological problems.
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 Scrotum and testes
• Observe normal/excess serous fluid, wall thickness of
scrotum, echo texture of epididymis, solid/cystic
epididymal masses and sizes, any peristalsis or gas.
• Testis- check for presence, size, echo texture, infarcts,
masses, torsion, fracture, micro- calcifications.
• Pampiniform plexus- check for presence of varicose
veins. Varicocoele may predispose to infertility in
men.
• Spermatic chord-

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 Breast
• Report should describe findings without
necessarily concluding.
• Lobes and lobules- normal/cystic and solid
lesions and their sizes, echo texture, precise
location. Localize lesions using clock face or
quadrants, 1, 2, 3 and A, B, C, surface distance.
• Lactiferous ducts- size, any occlusion?
• Axillary lymph nodes- size, shape, number and
location.
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 Thyroid
• Measure length, A-P diameter and width of both
lobes, check A-P diameter and length of isthmus.
• Check echo texture, echogenicity and contour or
micro-calcifications of each lobe.
• Describe nature of cysts and solid masses and
their location, including retrosternal extension of
each lobe, degenerating adenomas.
• Check if trachea is displaced from the midline.

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 Anterior neck
• Check for thyroglossal cysts, Submandibular
lymphadenopathy.

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 THANK YOU FOR LISTENING

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