Patient: [Patient Name]
Date: [Date of Encounter]
Reason for Exam:
Evaluation of a suspected liver lesion identified on prior imaging (ultrasound, CT scan, MRI)
Further characterization of a known liver lesion
Investigation of abnormal liver function tests (LFTs)
Staging of known malignancy
Procedure:
Contrast-enhanced ultrasound (CEUS) of the liver was performed using [contrast agent name] with [contrast agent dosage] following the manufacturer’s instructions.
Imaging was performed in [scan mode, e.g., real-time, harmonic] with particular attention to the [area of interest, e.g., suspicious lesion, entire liver].
Findings:
Liver size and echogenicity (normal, abnormal)
Presence and characteristics of any focal lesions:
Location (segment, lobe)
Size (cm)
Morphology (solid, cystic, mixed)
Enhancement pattern (arterial, portal venous, washout) – compared to surrounding liver parenchyma
Bile ducts (normal caliber, dilated)
Portal vein and hepatic veins (normal patency, thrombosis)
Other findings (ascites, fatty infiltration)
Impression:
Correlate with findings from previous imaging studies (if available).
Describe the CEUS findings of the liver, including the presence or absence of focal lesions and their characteristics.
Based on the enhancement pattern, suggest the likely nature of the lesion(s) (e.g., hemangioma, metastasis, focal nodular hyperplasia).
If a malignancy is suspected, further workup may be necessary for definitive diagnosis (biopsy).
Plan:
Continued monitoring with serial CEUS or other imaging studies (frequency depends on findings).
Liver biopsy (if indicated) to obtain tissue diagnosis.
Referral to a hepatologist or surgical oncologist for further management (if malignancy is suspected).
Discuss the findings and plan with the patient in an understandable manner.
Disclaimer:
CEUS findings should be interpreted in conjunction with the patient’s clinical history, laboratory tests, and other imaging studies.
Note:
This template provides a general framework for a contrast-enhanced ultrasound of the liver progress note. The specific content of the note will vary depending on the individual patient and the findings of the exam.