Documentație Medicală Automată

Ultrasound

PawfectNotes îți înregistrează consultația veterinară și generează automat o notă SOAP completă și precisă — fără dictare, fără scriere manuală.

Exemple de Documentație Medicală

Raport Ecografie

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

Vreți asta în formatul clinicii dvs.? Creați un șablon propriu

  • Subjective, Objective, Assessment, Plan complete
  • Detectare automată a numelui pacientului
  • Export cu 1 clic în EMR-ul tău
  • Funcționează în 41 de limbi

Cont Gratuit pentru Totdeauna