An ultrasound report is a formal medical document generated by a sonographer and interpreted by a radiologist. Its primary purpose is to translate the technical images produced by high-frequency sound waves into a concise, written communication for the referring physician. The report communicates specific measurements, observations, and professional assessments regarding the structures examined. Understanding the report’s structure and terminology allows patients to gain a clearer picture of the findings, which move from administrative details to observations and finally to the radiologist’s clinical judgment.
Navigating the Standard Report Structure
The initial section contains administrative details confirming the study’s identity and context. This includes the patient’s full name, date of birth, identification number, and the exact date and time the examination was performed. This information ensures the findings are correctly matched to the individual and provides a timestamp for comparisons with future or past scans.
Following the administrative data is the Clinical Indication, which states the specific reason the test was ordered, such as “right upper quadrant pain.” The Technique or Procedure section outlines how the scan was conducted, noting details like the type of ultrasound performed (e.g., transabdominal, transvaginal, or Doppler). This context helps the physician understand the limitations or specific focus of the imaging.
The report’s core is divided into two main parts: the Findings and the Impression. The Findings section contains the raw, detailed observations and measurements, often describing organs and any abnormalities in a systematic order. The Impression, or Conclusion, is situated at the end and represents the radiologist’s final opinion of the findings in relation to the clinical question.
Decoding Common Descriptive Terminology
The Findings section relies on specialized terminology to describe how tissues reflect sound waves, a property known as echogenicity. This property determines the brightness of structures on the ultrasound screen relative to surrounding tissues. Structures that appear bright or white are labeled hyperechoic because they reflect a large proportion of sound waves, often seen in bone or certain types of fat.
Conversely, tissues that reflect fewer sound waves are described as hypoechoic. A structure that appears completely black is termed anechoic or echo-free, which indicates it is filled with simple fluid, such as a cyst or blood vessel. When a structure has the same brightness as the tissue next to it, it is called isoechoic.
These terms are combined with descriptors of texture and composition. Homogeneous refers to a uniform, smooth appearance throughout an organ or structure, which is associated with healthy tissue. A heterogeneous texture suggests a non-uniform or varied appearance, which may indicate a disease process.
Structural terms differentiate observed masses. A cyst is a well-defined, spherical, fluid-filled structure that appears anechoic. A solid structure contains internal echoes and is tissue-filled, appearing hyperechoic, hypoechoic, or isoechoic. A complex lesion combines both fluid and solid components.
Interpreting the Impression and Recommendations
The Impression section is the most significant part of the report, distilling the technical findings into a concise clinical assessment. This section answers the question posed in the Clinical Indication and provides the radiologist’s judgment of the likelihood of a specific diagnosis. For instance, instead of listing measurements, the Impression might state “Right ovarian cyst, likely benign.”
Many ultrasound reports utilize standardized systems to provide a structured level of concern, particularly common in breast and thyroid imaging. The Breast Imaging Reporting and Data System (BI-RADS) assigns a score from 0 to 6 to breast findings, communicating the likelihood of malignancy. BI-RADS 1 means the test is negative, while BI-RADS 4 indicates a suspicious finding requiring a biopsy.
The Thyroid Imaging Reporting and Data System (TI-RADS) uses a point system based on features like composition and echogenicity to categorize thyroid nodules. TI-RADS scores, ranging from 1 to 5, correlate directly to the risk of cancer and guide management. The final part of the Impression often contains explicit recommendations for follow-up, such as a repeat ultrasound in six months or a recommendation for an additional imaging modality like a CT scan.