FAST POCUS 超音波報告格式
FAST
外傷超音波檢查報告( Focused Assessment with Sonography for Trauma, F.A.S.T. )
檢查適應症: TRUNK CONTUSION.
受傷部位：TRUNK
受傷類型：挫傷
檢查報告：(圖片粘貼於背面)
【RUQ】Pleural fluid: NEG
【Right Flank】Ascites in Morrison pouch: NEG
【Subxiphoid】Pericardial fluid: NEG
【LUQ】Pleural fluid: NEG
【Left Flank】Ascites in Splenorenal space: NEG
【Suprapubic】Ascites: NEG
超音波診斷：
No definite ascities
建議：
Educate the patient properly for increased chest or abdominal pain, fever, decreased appetite, or bruise should return for re-revaluation
急性創傷衛教告知
中超專業證字 eES000046號
POCUS. 尿管阻塞.
重點式超音波檢查報告 Point of Care Ultrasound Exam. ( POCUS )
檢查適應症: 尿不出來
檢查部位：膀胱
檢查報告：(圖片粘貼於背面)
【PELVIS】URINARY BLADDER DISTENSION. Foley CATHETER BALLOON IN UB.
【kidney】no hydronephrosis.
超音波診斷：
1. ACUTE URINE RETENTION
2. Foley CATHETER OBSTRUCTION.
建議：
CHANGE FOLEY CATHETER.
URINARY BLADDER IRRIGATION.
Uro OPD f/u.
中超專業證字 eES000046號
2016-12-17
適應症: 腹痛
檢查項目:腹部超音波
Ultrasonic Finding:
Liver: NEGATIVE FINDING.
Gallbladder: negative
Common bile duct: no dilatation
Portal vein: negative
Intrahepatic ducts: negative
Pancreas:negative
Spleen: negative
Right kidney: Hydronephrosis with dilated ureter was noted
Left kidney: negative
Ascites: no ascites
Aorta and IVC: negative
[Diagnosis]: Hydronephrosis with dilated ureter, right
[recommedation]
輸尿管結石衛教.
Check other cause of abdominal pain. Clinical correlation is suggested,
中超專業證字 eES000046號
2016-11-25 EDIT
外傷超音波檢查報告( Focused Assessment with Sonography for Trauma, F.A.S.T. )
檢查適應症:CHEST CONTUSION.
受傷部位：胸部
受傷類型：機車騎士與汽車擦撞. 胸部挫傷
檢查報告：(圖片粘貼於背面)
【CHEST】BILATERAL LUNG SLIDING NORMAL.
【RUQ】Pleural fluid: NEG
【Right Flank】Ascites in Morrison pouch: NEG
【Subxiphoid】Pericardial fluid: NEG
【LUQ】Pleural fluid: NEG
【Left Flank】Ascites in Splenorenal space: NEG
【Suprapubic】Ascites: NEG
超音波診斷：
No definite ascities
建議：
急性創傷衛教.
中超專業證字 eES000046號
外傷超音波檢查報告( Focused Assessment with Sonography for Trauma, F.A.S.T. )
檢查適應症:ABDOMINAL CONTUSION.
受傷部位：腹部
受傷類型：挫傷
檢查報告：(圖片粘貼於背面)
【RUQ】Pleural fluid: NEG
【Right Flank】Ascites in Morrison pouch: NEG
【Subxiphoid】Pericardial fluid: NEG
【LUQ】Pleural fluid: NEG
【Left Flank】Ascites in Splenorenal space: NEG
【Suprapubic】Ascites: NEG
超音波診斷：
No definite ascities
建議：
急性創傷衛教.
中超專業證字 eES000046號
32歲男性.右側腎結石疼痛
檢查項目:腹部超音波 Ultrasonic Finding:
Liver: NEGATIVE FINDING.
Gallbladder: negative
Common bile duct: no dilatation
Portal vein: negative
Intrahepatic ducts: negative
Pancreas:negative
Spleen: negative
Right kidney: Hydronephrosis with dilated ureter was noted (10.7 cm in long axis);
Left kidney: negative (10 cm in long axis);
Ascites: no ascites
Aorta and IVC: negative
[Diagnosis]: Hydronephrosis with dilated ureter, right
[recommedation]輸尿管結石衛教. URO OPD F/U.
中超專業證字 eES000046號
21歲女性腸沾黏(小時候開腸套疊)
Point of Care Ultrasound Exam ( POCUS )
檢查適應症: ABDOMINAL PAIN.
檢查報告：(圖片粘貼於背面)
【Liver】No obvious parenchymal lesion.
【GB】No wall thickening.
【CBD】No dilatation.
【Aorta】No AAA.
【Kidney】bilateral hydronephrosis.
【Bowel】Small bowel ileus with minumal ascites.
【pelvis】minimal ascites was noted.
【Uterine】: no obvious finding.
Impression: Small bowel ileus. suspect adhesion ileus.
SUGGESTION： admission. NPO. IV hydration. NG decompression.
中超專業證字 eES000046號
重點式超音波檢查報告 Point of Care Ultrasound Exam. ( POCUS )
檢查適應症: 尿不出來
檢查部位：膀胱
檢查報告：(圖片粘貼於背面)
【PELVIS】URINARY BLADDER DISTENSION.
【kidney】no hydronephrosis.
超音波診斷：ACUTE URINE RETENTION
建議：ON FOLEY CATHETER. Uro OPD f/u.
中超專業證字 eES000046號
重點式超音波檢查報告 ( Focused Assessment with Sonography)
檢查適應症: DYSURIA
檢查部位：膀胱
檢查報告：(圖片粘貼於背面)【PELVIS】URINARY BLADDER DISTENSION.
超音波診斷：ACUTE URINE RETENTION
建議：FOLEY CATHETERIZATION.
中超專業證字 eES000046號
重點式超音波檢查報告 ( Focused Assessment with Sonography)
檢查適應症: DYSURIA
檢查部位：膀胱
檢查報告：(圖片粘貼於背面)
【PELVIS】URINARY BLADDER DISTENSION.
超音波診斷：FOLEY CATHETER OBSTRUCTION
建議：CHANGE FOLEY CATHETER.
中超專業證字 eES000046號
重點式超音波檢查報告( Focused Assessment with Sonography)
檢查適應症: LOW ABDOMINAL PAIN.
檢查部位：骨盆腔
檢查報告：(圖片粘貼於背面)
【PELVIS】NO CYST OR ASCITES WAS FOUND.
超音波診斷：
PELVIC REGION PAIN, NATURE TO BE DETERMINED.
建議：PURSUE URINE ANALYSIS RESULT. Clinical correlation is suggested,
41歲女性. 腹痛
重點式超音波檢查報告( Focused Assessment with Sonography)
檢查適應症: ABDOMINAL PAIN.
檢查部位：骨盆腔
檢查報告：(圖片粘貼於背面)
【GB】NO STONE. GB WALL NORMAL. NO SONOGRAPHIC MURPHY'S SIGN.
【LIVER】NO MASS LESION. CBD 0.5CM. NO ASCITES
【PANCREAS】BODY WNL. HEAD AND TAIL: POOR WINDOW.
【PELVIS】NO CYST OR ASCITES WAS FOUND. NO ASCITES
超音波診斷：
NEGATIVE SONOGRAPHIC FINDING.
建議：Clinical correlation is suggested,
中超專業證字 eES000046號
51歲女性腹痛. (其實還有MYOMA, 但已經知道很久了, 沒打上去)
重點式超音波檢查報告( Focused Assessment with Sonography)
檢查適應症: LOW ABDOMINAL PAIN. RIGHT BACK PAIN.
檢查部位：ABDOMEN
檢查報告：(圖片粘貼於背面)
【PELVIS】URINARY BLADDER DISTENSION.【RIGHT FLANK 】NO HYDRONEPHROSIS.
超音波診斷：
1. ACUTE URINE RETENTION2. ABDOMINAL PAIN CAUSE TO BE DETERMINED.
建議：PURSUE URINE ANALYSIS RESULT. Clinical correlation is suggested,
81歲阿罵. 三天前胸壁挫傷. 所以這次我不是CHARGE FAST.
重點式超音波檢查報告( Focused Assessment with Sonography)
檢查適應症: CHEST CONTUSION.
受傷部位： 胸部
受傷類型：挫傷
檢查報告：(圖片粘貼於背面)
【CHEST】BILATERAL LUNG SLINDING SIGN NORMAL. NO PERICARDIAL EFFUSION
【RUQ】Pleural fluid: NEG
【Right Flank】Ascites in Morrison pouch: NEG
【Subxiphoid】Pericardial fluid: NEG
【LUQ】Pleural fluid: NEG
【Left Flank】Ascites in Splenorenal space: NEG
【Suprapubic】Ascites: NEG
超音波診斷：
No definite ascities. NEGATIVE FINDING.
建議：Educate the patient properly for increased chest pain, shortness of breath, dyspnea, fever, decreased appetite, or bruise should return for re-revaluation急性腹痛衛教
中超專業證字 eES000046號
剛看到泌尿科醫師的超音波報告(輸尿管結石的病人), 真簡略.
RK Dilated renal pelvis
LK NORMAL RENAL CONTOUR
IMP : R'T Hydronephrosis
龍哥的超音波報告(AGE)
超音波診斷：c/w enterocolitis.
Plan: Clinical correlation.
Point of Care Ultrasound Exam. ( POCUS )
檢查適應症: r/o enteritis.
檢查報告：(圖片粘貼於背面)
【Liver】No obvious parenchymal lesion.
【GB】No wall thickening. Polyps, about 0.5 cm.
【CBD】No dilatation.
【Aorta】No AAA.
【Kidney】No hydronephrosis.
【Bowel】Small bowel dilatation with peristalsis. Distal A-colon and proximal T-colon swelling. No obvious wall thickening.
【Othes】No ascites.
有些醫師的超音波報告. 不喜歡放證書字號.
檢查項目: 腹部超音波
Ultrasonic Finding:
Liver: slightly bright echogenicity with regular surface and normal margins . Heterogenous echogenicity. A 0.33cm hyperechoic lesion was noted at S8.
Gallbladder: A 3.96cm hyperechoic lesion with strong PAS was noted. Because of strong PAS, I can not observe the beneath structure.
Common bile duct: no dilatation
Portal vein: negative
Intrahepatic ducts: negative
Pancreas: tail is masked by gas
Spleen: no enlargement
Left kidney: negative (9.51 cm in long axis);
Right kidney: A 0.88cm anechoic cystic lesion was noted (10.86 cm in long axis);
Ascites: no ascites
Aorta and IVC: negative
[Diagnosis]:
1. fatty liver, mild
2. parenchymal liver diease
3. Renal cyst, right
4. GB stone
5. Incomplete study of pancreas
[recommedation] please correlate with clinical condition; Elective cholecystectomy is considered because "GB stone >2.5cm" is a risk factor of GB cancer.
Owen的POCUS 報告.
30歲女性上腹痛. WBC 17000急診超音波檢查報告 ( Focused Emergency Ultrasound)
INDICATION(適應症)：ABDOMINAL PAIN
FINDINGS(超音波發現)：(圖片粘貼於背面)
Ascites: ■Negative □Positive ( □Morrison's pouch □Splenorenal recess □Suprapubic) Aorta: ■Normal □AAA, diameter ______cm □DissectionBiliary tract: □No obvious lesion □Acute cholecystitis ■CBD dilation □OtherKidney: ■No obvious lesion □Hydronephrosis □Renal stone □OtherGastrointestinal system: ■No obvious lesion □Acute appendicitis □Ileus □Pneumoperitonium □OtherOthers:
DIAGNOSIS(超音波診斷)： 1. CBD dilation
SUGGESTION(建議)：1. Arrange GI ultrasound2. Further exam if needed
Point of Care Ultrasound Exam. ( POCUS )檢查適應症: Low abdominal pain. suspect ectopic pregnant or corpus leutum rupture.
檢查報告：(圖片粘貼於背面)
【Left flank】 negative for ascites.
【Right flank】 negative for ascites. right kidney cysts.
【central abdomen】negative for ascites.
【Pelvis】 minimal ascites was noted around uterine.
Impression: Minimal ascites. suspect internal bleeding.
SUGGESTION：Clinical correlation is suggested, 外傷衛教. 中超專業證字 eES000046號
Point of Care Ultrasound Exam ( POCUS )檢查適應症: ABDOMINAL PAIN. 檢查報告：(圖片粘貼於背面)【Liver】No obvious parenchymal lesion.【GB】No wall thickening.【CBD】No dilatation. 【Aorta】No AAA.【Kidney】bilateral hydronephrosis.【Bowel】Small bowel ileus with minumal ascites. 【pelvis】minimal ascites was noted. 【Uterine】: no obvious finding.
Impression: Small bowel ileus. suspect adhesion ileus.
SUGGESTION：admission. NPO. IV hydration. NG decompression.
中超專業證字 eES000046號
檢查項目:腹部超音波 Ultrasonic Finding: Liver: NEGATIVE FINDING. Gallbladder: negative Common bile duct: no dilatation Portal vein: negative Intrahepatic ducts: negative Pancreas:negative Spleen: negative Right kidney: Hydronephrosis with dilated ureter was noted (10.7 cm in long axis);Left kidney: negative (10 cm in long axis);Ascites: no ascitesAorta and IVC: negative[Diagnosis]: Hydronephrosis with dilated ureter, right
[recommedation]輸尿管結石衛教. URO OPD F/U.
中超專業證字 eES000046號
乳房超音波報告 MODERATED DENSE BREAST TISSUENO DEFINITE TUMOR UNDER ECHOFIBROCYSTIC CHANGEBI-RADS: 2F/U
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