Vet AI Scribe for Diagnostic Imaging

Duke

Wednesday, August 26, 2026 at 9:30 AM

Abdominal ultrasound report — referred by Dr. Lena Hart, Maple Grove Animal Hospital

Patient and Clinical History

• 11-year-old neutered male Golden Retriever, 36.4 kg.
• Referred for a cranial abdominal mass palpated at his annual exam and an ALP of 486 U/L (reference 5–160) on in-house chemistry.
• Mild weight loss (1.8 kg over 6 months); appetite and energy reported as normal.
• Abdominal radiographs from the referring clinic (August 19): rounded soft tissue opacity in the left cranial abdomen, caudal to the liver, displacing the stomach to the right.
• PCV 41% on the day of the scan.

Technique

• Complete abdominal ultrasound, right and left lateral recumbency, with microconvex and linear transducers.
• Patient clipped; no sedation required.
• Images and cine loops archived to the clinic PACS.

Findings

Liver

• Large, well-marginated, heterogeneous mass arising from the left lateral liver lobe, measuring 6.2 × 5.8 × 5.4 cm, with several small anechoic cavitations. Moderate internal blood flow on colour Doppler.
• The remaining liver parenchyma is normal in size and echogenicity, with no other nodules identified.
• Portal vein and hepatic veins normal; caudal vena cava not invaded.

Gallbladder

• Small amount of gravity-dependent, non-shadowing sludge. Wall thin (1.5 mm). Common bile duct not dilated.

Spleen

• Normal size. Two hypoechoic nodules in the tail: 0.6 cm and 0.8 cm. No cavitation or capsular irregularity.

Kidneys

• Left kidney 7.8 cm, right kidney 7.6 cm in length. Normal corticomedullary definition. No pyelectasia or calculi.

Adrenal Glands

• Left adrenal 0.6 cm caudal pole thickness, right 0.7 cm. Normal shape; no vascular invasion.

Urinary Bladder

• Moderately distended, anechoic urine. Wall smooth and normal thickness. No calculi or masses.

Gastrointestinal Tract

• Stomach displaced to the right by the hepatic mass; wall layering normal. Small intestine and colon normal in thickness and layering, with normal motility.

Pancreas

• Right limb visualised; normal size and echogenicity.

Lymph Nodes

• Hepatic and splenic lymph nodes not enlarged. Medial iliac lymph nodes normal (0.5 cm).

Peritoneum

• No free fluid. Mesentery normal.

Impression

1. Solitary left lateral liver lobe mass (6.2 × 5.8 × 5.4 cm), cavitated and vascular. Hepatocellular adenoma or carcinoma is most likely given the solitary, well-marginated appearance; haemangiosarcoma and other sarcomas cannot be excluded on imaging. No sonographic evidence of vascular invasion.
2. Two small hypoechoic splenic nodules (0.6 and 0.8 cm) — nodular hyperplasia is most common at this age; metastatic disease cannot be ruled out.
3. Mild biliary sludge, likely incidental.
4. No peritoneal effusion and no abdominal lymphadenopathy.

Recommendations

• Three-view thoracic radiographs or thoracic CT to screen for pulmonary metastases before surgery.
• Contrast CT of the abdomen for surgical planning of a left lateral liver lobectomy; CT can also help characterise the splenic nodules.
• Coagulation profile (PT, aPTT) and platelet count before any sampling or surgery.
• Fine-needle aspiration of the liver mass is not recommended given its cavitation and vascularity; definitive diagnosis on histopathology after excision.
• Splenic nodules can be aspirated at the time of CT or monitored by ultrasound in 4–6 weeks if surgery proceeds.
• Happy to discuss the case or review the CT with you.

— Dr. Samuel Achebe, DVM, DACVR
Diagnostic Imaging Service