Can you help me write a procedure note for an abdominal ultrasound in a 48‑year‑old male with a BMI of 32 kg/m², type 2 diabetes mellitus on metformin, and occasional alcohol use, to evaluate for hepatic steatosis and perform a comprehensive abdominal assessment?

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Last updated: September 27, 2026 • View editorial policy

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Abdominal Ultrasound Procedure Note Template for Hepatic Steatosis Evaluation

For a patient with type 2 diabetes, obesity (BMI 32), and metabolic risk factors, perform a comprehensive abdominal ultrasound with specific focus on hepatic steatosis grading using standardized criteria, as ultrasound is the appropriate first-line noninvasive screening tool for fatty liver disease in this high-risk population 1.

Pre-Procedure Documentation

Patient Demographics & Indication:

  • Age, sex, BMI (document if ≥30 kg/m²)
  • Type 2 diabetes status and current medications (specifically metformin use)
  • Alcohol consumption pattern (to differentiate NAFLD from alcohol-induced steatosis)
  • Primary indication: Evaluation for hepatic steatosis in patient with T2DM and obesity (prevalence approaches 90% in diabetic patients with obesity) 1

Technical Approach

Equipment & Settings:

  • Use curvilinear transducer (3.5-5 MHz)
  • Patient positioning: Supine, left lateral decubitus as needed
  • Fasting status: Document if patient fasted (improves visualization)

Systematic Examination Protocol

1. Hepatic Steatosis Assessment (Primary Focus)

Qualitative Grading - Compare liver to right kidney cortex echogenicity:

  • Grade 0 (Normal): Liver echogenicity equal to or slightly higher than renal cortex; clear visualization of diaphragm and intrahepatic vessel walls
  • Grade 1 (Mild): Mild diffuse increase in liver echogenicity with clear definition of diaphragm and intrahepatic vessel walls
  • Grade 2 (Moderate): Moderate diffuse increase in liver echogenicity with obscuration of diaphragm and intrahepatic vessel walls
  • Grade 3 (Severe): Marked increase in liver echogenicity with non-visualization of diaphragm and intrahepatic vessel walls 1

Quantitative Assessment - Hepatorenal Index (Recommended):

  • Measure echogenicity ratio of liver parenchyma to right kidney cortex
  • This method shows 99.2-99.6% correlation with MR spectroscopy and biopsy for mild steatosis detection
  • Superior to qualitative assessment as it's independent of BMI, inflammation, or fibrosis 1
  • Document the numerical ratio

Critical Caveat: Ultrasound sensitivity drops significantly for mild steatosis (53-65% sensitivity) but maintains 84.8% sensitivity for moderate-severe steatosis (>30% fat content) 1. If clinical suspicion remains high despite negative ultrasound, consider advanced imaging.

2. Liver Morphology & Size

  • Measure liver span in midclavicular line
    • Critical threshold: ≥16.4 cm in males or ≥16.8 cm in females predicts hepatic fibrosis in diabetic patients 2
  • Assess for:
    • Surface nodularity (suggests cirrhosis)
    • Caudate lobe hypertrophy (cirrhosis indicator)
    • Focal fatty sparing or focal steatosis patterns

3. Portal Venous System

  • Portal vein: Measure diameter (normal <13 mm), assess flow direction and velocity
  • Hepatic veins: Evaluate flow pattern
    • Normal: Triphasic waveform
    • Abnormal finding: Monophasic flow suggests fat deposition, inflammation, or fibrosis 1
  • Hepatic artery: Measure resistive index if Doppler capability available

4. Comprehensive Abdominal Survey

Gallbladder:

  • Assess for cholelithiasis, wall thickening, polyps
  • Note: NAFLD patients have increased gallstone risk

Pancreas:

  • Evaluate head, body, tail for masses or ductal dilation
  • Document pancreatic echogenicity (fatty infiltration common in metabolic syndrome)

Spleen:

  • Measure size (splenomegaly suggests portal hypertension)

Kidneys (bilateral):

  • Size, echogenicity, cortical thickness
  • Assess for stones, masses, hydronephrosis
  • Critical in diabetic patients: Document any evidence of diabetic nephropathy (increased echogenicity, loss of corticomedullary differentiation)

Abdominal Aorta:

  • Measure diameter, assess for aneurysm or atherosclerotic changes

Ascites:

  • Document presence/absence (suggests advanced liver disease)

Procedure Note Template

PROCEDURE: Abdominal Ultrasound with Focus on Hepatic Steatosis

INDICATION: Screening for hepatic steatosis in 48-year-old male with type 2 diabetes mellitus (BMI 32 kg/m²), on metformin, with occasional alcohol use

TECHNIQUE: Real-time grayscale and color Doppler ultrasound of the abdomen performed using curvilinear transducer. Patient fasting status: [document]. Multiple images obtained in standard planes.

FINDINGS:

LIVER:

  • Size: Liver span measures [X] cm in midclavicular line (normal <16.4 cm males, <16.8 cm females)
  • Echogenicity: [Grade 0/1/2/3 steatosis using criteria above]
  • Hepatorenal Index: [X.XX] (quantitative assessment)
  • Contour: Smooth/nodular
  • Focal lesions: None identified / [describe if present]
  • Intrahepatic bile ducts: Not dilated

PORTAL VENOUS SYSTEM:

  • Portal vein: Patent, hepatopetal flow, diameter [X] mm
  • Hepatic veins: Triphasic/monophasic flow pattern
  • Hepatic artery resistive index: [if measured]

GALLBLADDER: Normal/[findings]

PANCREAS: Visualized portions appear normal/[findings]

SPLEEN: Normal size, measures [X] cm / Splenomegaly present

KIDNEYS:

  • Right: [size] cm, normal echogenicity, no hydronephrosis, no stones
  • Left: [size] cm, normal echogenicity, no hydronephrosis, no stones
  • Corticomedullary differentiation: Preserved/reduced

ABDOMINAL AORTA: Normal caliber, no aneurysm

ASCITES: None / Present [describe]

IMPRESSION:

  1. [Grade] hepatic steatosis (hepatorenal index: [X.XX])
  2. [Additional findings]

CLINICAL CORRELATION:

  • Patient has T2DM with BMI 32 kg/m², placing them in the 90% prevalence category for NAFLD 1
  • [If liver span ≥16.4/16.8 cm]: Liver span exceeds threshold predictive of hepatic fibrosis; recommend FIB-4 index calculation and consideration for elastography 2
  • [If moderate-severe steatosis]: Recommend metabolic optimization, lifestyle modification, and consideration of hepatology referral for fibrosis assessment

Post-Procedure Management Recommendations

Based on findings, stratify risk:

  • No/mild steatosis: Annual monitoring, lifestyle modification
  • Moderate-severe steatosis: Calculate FIB-4 index; if elevated, proceed to transient elastography (FibroScan) for fibrosis staging 1, 3
  • Liver span ≥16.4 cm (males) or ≥16.8 cm (females): High suspicion for fibrosis, recommend elastography 2

Key Clinical Pitfall: Ultrasound cannot reliably distinguish simple steatosis from steatohepatitis (NASH) or exclude early fibrosis. Patients with diabetes have 25-30% risk of NASH and accelerated fibrosis progression 1. Do not rely on ultrasound alone for risk stratification in diabetic patients with steatosis—proceed to non-invasive fibrosis assessment.

References

1
Guideline

acr appropriateness criteria® abnormal liver function tests.

Journal of the American College of Radiology, 2023

3
Guideline

acr appropriateness criteria<sup>®</sup> chronic liver disease.

Journal of the American College of Radiology, 2017

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