Standard phrases for the medical record
Copy a phrase directly into the record. Always adapt the text to the individual patient.
Normal examination (fully written out)
Abdominal POCUS performed as part of the AbdoPOCUS trial. Good/reasonable/limited/difficult imaging conditions. All 8 protocol views scanned (or state which are missing). Patient fasting (for x hours)/non-fasting. The aorta is visualised from below the xiphoid process to the bifurcation, eyeballed to < 3 cm. No sign of aortic aneurysm. The gallbladder is non-dilated and without calculi, acoustic shadowing or sludge. The gallbladder wall is thin. No transducer tenderness. The liver/Morison's pouch shows no surrounding free fluid. The kidneys show no hydronephrosis. The spleen/splenorenal recess shows no surrounding free fluid. The bladder shows no urinary retention (measured at xx mL). No free fluid around the bladder. The small bowel shows no dilated segments. Normal bowel wall and normal peristalsis. No free fluid around the bowel.
Pathological findings
The phrases describe the possible POCUS findings. Always adapt the text to the individual patient so it describes only what you actually found.
Aorta – abdominal aortic aneurysm (AAA)
The aorta measures xx cm in antero-posterior diameter (> 3 cm), consistent with an abdominal aortic aneurysm (AAA). [Describe mural thrombus if present.]
Gallbladder – gallstones
The gallbladder contains sludge and calculus/calculi with acoustic shadowing, consistent with gallstones. Normal thin gallbladder wall, no fluid around the gallbladder.
Gallbladder – acute cholecystitis
The gallbladder wall is thickened (> 3 mm), with gallstones, acoustic shadowing and sludge. Pericholecystic fluid and transducer tenderness are present, consistent with acute cholecystitis.
Liver/Morison's pouch – free fluid
Free fluid is seen at the liver/Morison's pouch.
Kidneys – hydronephrosis
Hydronephrosis is present. [State side (right/left/bilateral) and grade (mild/moderate/severe).]
Spleen/splenorenal recess – free fluid
Free fluid is seen at the spleen/splenorenal recess.
Bladder – urinary retention
The bladder is dilated with an estimated volume of xx mL (height x width x length x 0.7), consistent with urinary retention.
Bladder – free fluid
Free fluid is seen in the pouch of Douglas/rectovesical pouch.
Small bowel – small bowel obstruction
Dilated small bowel loops > 2.5 cm with a thickened bowel wall and keyboard sign. In addition, to-and-fro movement and reduced/absent peristalsis. Free fluid is seen around the small bowel loops, consistent with small bowel obstruction.