Report template

Report template — Ultrasound of globe ocular

Ultrasound report template for globe ocular — clinical body in pt-BR with [...] placeholders for exam-specific findings.

When to use

Cervical and soft-tissue US is useful for palpable neck masses, lymphadenopathy, salivary gland disease, superficial skin/subcutaneous lesions and collections. Transfontanellar US is the initial method in neonates for IVH and hydrocephalus.

What to evaluate

  • Lymph nodes: morphology, central hilum, cortical thickness, Doppler vascularity.
  • Salivary glands: size, echotexture, stones (sialolithiasis), focal lesions.
  • Superficial masses: size, composition, involved planes, vascularity.
  • In neonates (transfontanellar): ventricles, parenchyma, hemorrhage, ischemia.

Interactive template

Fill the blanks0/0

DIREITO - Córnea: de contornos regulares. - Câmara anterior: com ecogenicidade preservada. - Cristalino: normal. - Câmara vítrea: com contornos regulares e conteúdo anecogênico homogêneo. - Deslocamento de retina: negativo. - Corpo estranho: não há. - Nervo óptico: com ecotextura e morfologia preservadas. - Massas retrobulbares: ausentes. - Musculatura extrínseca: com ecotextura e morfologia preservadas. ESQUERDO - Córnea: de contornos regulares. - Câmara anterior: com ecogenicidade preservada. - Cristalino: normal. - Câmara vítrea: com contornos regulares e conteúdo anecogênico homogêneo. - Deslocamento de retina: negativo. - Corpo estranho: não há. - Nervo óptico: com ecotextura e morfologia preservadas. - Massas retrobulbares: ausentes. - Musculatura extrínseca: com ecotextura e morfologia preservadas. Conclusão: - Exame sem achados significativos.
Template in Brazilian Portuguese (clinical reporting language). Adapt to your service protocol. Not medical advice — the physician reviews, edits and signs.

How to use

  • Replace each [...] with the exam's measurement or descriptor.
  • Adapt the conclusion to your service protocol before signing.
  • Use the template as a starting point — not a replacement for physician review.
  • In Laudos.AI, dictate findings in natural speech and the AI structures text in this format for review.

Frequently asked

Suspicious vs reactive lymph node — criteria?
Reactive: oval, preserved central hilum, hilar vascularity. Suspicious: round (S/L > 0.5), hilum loss, peripheral/chaotic vascularity, microcalcifications, central necrosis.
Cervical cystic lesion — differentials?
Branchial cleft cyst (lateral, 2nd arch — adjacent to SCM), thyroglossal cyst (midline, suprahyoid), cystic hygroma, abscess, lymphangioma. Location + echostructure orient the differential.
Transfontanellar US — useful window?
Until anterior fontanelle closure (typically 12–18 months). After that, MRI is the imaging method in neonatal emergency.

References

  • ACR–AIUM–SPR–SRU Practice Parameter for the Performance of an Ultrasound Examination of the Head and Neck.

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