英文超声报告怎么写？看过这四例就有数了。。。
摘要： 英文超声报告是使用标准化、专业化的医学术语，客观描述超声检查所见并提供临床印象的正式医疗文书，常用于国际医疗交流或涉外医疗机构中。
- 英文超声报告需包含患者信息、检查类型、详细发现（Findings）和临床印象（Impression）四部分。
- 报告语言应使用统一、科学、通用的超声医学术语，避免主观判断。
- 正常结果也需明确表述，如“No sonographic abnormality”或“Negative ultrasound”，以供临床参考和法律存档。
- 不同部位的超声报告结构相似，但描述重点依解剖结构和临床关注点而异。
小白老师说：超声检查报告是临床诊治的重要参考依据之一，又是法律纠纷处理中的参考资料，所以必须认真客观地详细描述检查内容，供临床医师参考。报告中专业用词必须是统一的、科学的、通用的超声医学术语。今天给大家提供四例英文超声报告，供大家参考。
Sample #1 : Gallbladder Ultrasound Report
范本1：胆囊超声报告
PATIENT NAME: Debra Jones
ID NUMBER: 240804
REFERRING PHYSICIAN: Dr. Harry Richard
DATE OF SERVICE: 12/01/16
D.O.B.:
GALLBLADDER ULTRASOUND
FINGDINGS
The gallbladder appears normal. There is no gallstones, gallbladder wall thickening or pericholecystic fluid. There is no notation of the intra or extrahepatic biliary system. The common bile duct measures 1.1 cm.
IMPRESSION
No sonographic abnormality of the gallbladder is identified.
Sample #2：Renal Ultrasound Report
范本2：肾脏超声报告
PATIENT NAME: Debra Jones
ID NUMBER: 240804
REFERRING PHYSICIAN: Dr. Harry Richard
DATE OF SERVICE: 12/01/16
D.O.B.:
RENAL ULTRASOUND
FINDINGS
The right kidney measures 9 cm in length and the left kidney measures approximately 10.6 cm in length. There is no hydronephrosis, nephrolithiasis or renal mass. There is no perinephric fluid collection.
IMPRESSION
No sonographic abnormality of the kidneys is identified.
Sample #3：Scrotal Ultrasound Report
范本3：阴囊超声报告
RE: Debra Jones
DATE: 12/01/15
MR: 240804
DOB: 12/01/65
SCROTAL ULTRASOUND
FINDINGS
Both testicles are normal in size, contour and echogenicity. The right testicle measures 5.2 x 2.2 x 3.6 cm and the left testicle measures 5.0 x 2.3 x 3.3 cm. There is normal Doppler flow to both testicles. The right epididymis measures 1.0 x 0.3 x 0.3 cm. The left epididymis is slightly larger measuring 1.1 x 0.7 x 0.5 cm.
There is a normal amount of fluid within the scrotum. There is no hernia identified within the right groin containing bowel.
IMPRESSION
NEGATIVE SCROTAL ULTRASOUND.
Sample #4：Venous Doppler Report
范本4：静脉多普勒报告
PATIENT NAME: Debra Jones
ID NUMBER: 240804
REFERRING PHYSICIAN: Dr. Harry Richard
DATE OF SERVICE: 12/01/16
D.O.B.:
BILATERAL LOWER EXTREMITY VENOUS DOPPLER（双侧下肢静脉多普勒 ）
FINDINGS
Both common femoral veins, superficial femoral veins, popliteal veins and posterior tibial veins exhibited normal flow, compressibility and augmentation.
IMPRESSION:
NO EVIDENCE OF DEEP VENOUS THROMBOSIS IN EITHER LEG.
**发送关键词 “超声” 到公众号，可获得超声科常用医学英语词汇（中英文对照版）总结。
常见问题
英文超声报告的基本结构是什么？
通常包括患者基本信息、检查项目、检查所见（Findings）和诊断印象（Impression）四个部分。
为什么英文超声报告要用标准化术语？
标准化术语确保报告在临床诊疗和法律场景中具有准确性和可比性，避免歧义。
正常超声结果在英文报告中如何表达？
常用表述如“No sonographic abnormality is identified”或“Negative ultrasound”来明确说明未见异常。
参考资料
超声科常用医学英语词汇（中英文对照版）
可通过关注原文公众号并发送关键词“超声”获取。