Medical record example

AI-Generated Veterinary Ultrasound

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Example Medical Record

Ultrasound

Fluffy

Thursday, July 30, 2026 at 4:07 PM

Ultrasound Note

Presenting Complaint

Routine wellness screening for internal organ assessment.

Owner Concerns

Owner requested a general abdominal ultrasound to ensure internal health status; no specific complaints reported.

Limitations of Study

No limitations were encountered during the study. The patient was cooperative, and image quality was satisfactory.

General Findings

The abdominal ultrasound reveals no significant abnormalities. All evaluated organs exhibit normal structure and echogenicity.

Detailed Findings

  • Adrenal Gland - Left: Normal in size and shape with clearly defined margins. No nodules or masses visualized.
  • Adrenal Gland - Right: Normal echotexture, symmetrical to the left, and free of focal lesions.
  • Free Fluid: No peritoneal or retroperitoneal free fluid identified.
  • Gallbladder: Moderately distended with homogeneously anechoic bile. No choleliths, sludge, or mural thickening.
  • Kidney - Left: Normal renal architecture with distinct corticomedullary definition. No evidence of mineralization, hydronephrosis, or mass effect.
  • Kidney - Right: Symmetrical in size and appearance to the left. No nephroliths or abnormalities noted.
  • Large Intestine: Wall layering intact; normal thickness and motility. No signs of colitis, obstruction, or foreign material.
  • Liver: Homogeneous parenchyma with smooth margins. No focal hepatic lesions or evidence of hepatomegaly.
  • Mesenteric Lymph Nodes: All nodes within normal size and echotexture. No enlargement or irregular margins seen.
  • Pancreas: Pancreas clearly visualized, with normal lobular pattern and echogenicity. No peripancreatic inflammation or masses.
  • Reproductive Organs: Gonadal structures appropriate for species and sex; uterus/prostate within normal limits.
  • Small Intestines: Normal wall layering and peristalsis throughout. No luminal obstruction, thickening, or abnormal content.
  • Spleen: Spleen of normal echotexture and size. No masses, nodular changes, or splenomegaly noted.
  • Stomach: Collapsed but normal in wall thickness and mucosal pattern. No foreign material, ulceration, or fluid retention.
  • Urogenital Organs:
    • Urinary Bladder: Well distended with anechoic contents. Bladder wall is uniformly thin and smooth. No stones, sediment, or mural abnormalities.
    • Urethra (visualized distal portion): Appears normal.
Generated by PawfectNotes

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Why vets choose PawfectNotes for Ultrasound Reports

  • Auto-generates in seconds
  • Accurate clinical terminology
  • Customizable templates
  • Voice dictation + real-time editing

Frequently Asked Questions

  • Are these templates customizable?Yes. Set your default template, choose your specialty and your own normal findings for the SOAP note, or duplicate a built-in template and change it to match your EMR format.
  • Can I add my own note types?Yes โ€” build your own template in Templates (sections, fields, formats) and share it with your practice. See how customization works.

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