Upper Endoscopic Ultrasound (EUS) Procedure Report

Patient: [Full name] | MRN: [MRN] | DOB: [DOB] | Sex: [Sex]

Date/Time: [Encounter date] [Start time] | Location: [Facility/Unit]

Procedure: [Procedure type(s) performed (e.g., EUS with FNB / EGD + Linear EUS / Radial EUS)] | Endoscopist: [Primary endoscopist] | Assistant(s): [Assistant(s) / None] | Referring Clinician: [Referring clinician / Unknown]

Indication

[Clinical question driving the procedure] (State in 1–2 sentences; if multiple, list in order of clinical priority.)

Pertinent Clinical Context

• [Key prior imaging relevant to the indication] (Summarize only critical findings; if outside imaging unavailable, state: "Outside imaging unavailable.")
• [Relevant medical/surgical history impacting risk or interpretation] (e.g., cirrhosis, prior pancreatitis, altered anatomy)
• [Pertinent labs influencing interpretation] (e.g., bilirubin, INR, tumor markers; include values and dates if available)
• [Antithrombotic management status] (e.g., held/continued, bridging, timing; omit if not applicable)

Consent

[Informed consent obtained from patient / legally authorized representative]. Procedures discussed: [EGD, EUS, tissue sampling anticipated / not anticipated]. Material risks emphasized: [bleeding, perforation, infection, pancreatitis, aspiration, cardiopulmonary events, failure to obtain diagnosis]. [Alternatives discussed if relevant].

Sedation/Anesthesia

Type: [Moderate sedation / MAC / General anesthesia] | Provider: [Anesthesiologist / CRNA / Proceduralist / N/A]

[Sedation agents and dosing details] (List agents and doses if documented; otherwise state: "Per anesthesia record.")

Equipment and Technique

• Echoendoscope: [Linear / Radial] (Include scope model if required by facility policy.)
• Adjunct imaging: [None / Doppler / Contrast-enhanced EUS / Elastography]
• Technique notes: [Key technical details impacting interpretation] (Optional; e.g., water-fill, balloon inflation.)

Extent and Completeness

• Endoscopic extent: [Diagnostic EGD performed; scope advanced to second portion of duodenum / Other extent]. [Significant luminal findings relevant to indication, if any].
• Completeness: [Examination adequate for indication / Limited examination due to [reason]; [stations/targets] not assessed]

EUS Examination

(Organize by scope position. For each position, list structures evaluated with normal vs abnormal descriptors. Explicitly mark "Not evaluated" with a brief reason for any relevant structure not assessed. Include pertinent negatives when clinically required.)

Esophagus/GEJ Position

• Mediastinum/paraesophageal region: [Normal / Abnormal: [descriptor] / Not evaluated: [reason]]
• Regional lymph nodes: [None identified / Present: [location/station, size, characteristics] / Not evaluated: [reason]]
• Other: [Findings / Not evaluated: [reason]]

Stomach Position

• Left lobe of liver: [Normal / Abnormal: [descriptor] / Not evaluated: [reason]]
• Celiac axis/perivascular region: [Normal / Abnormal: [descriptor] / Not evaluated: [reason]]
• Pancreas—body/tail: [Normal / Abnormal: [descriptor] / Not evaluated: [reason]]
• Regional lymph nodes: [None identified / Present: [station, size, characteristics] / Not evaluated: [reason]]
• Other: [Findings / Not evaluated: [reason]]

Duodenal Bulb Position

• Pancreas—head/neck: [Normal / Abnormal: [descriptor] / Not evaluated: [reason]]
• Pancreatic duct: [Normal caliber / Dilated: [measurement, extent] / Not evaluated: [reason]]
• Common bile duct: [Normal caliber / Dilated: [measurement] / Not evaluated: [reason]]
• Regional lymph nodes: [None identified / Present: [station, size, characteristics] / Not evaluated: [reason]]
• Other: [Findings / Not evaluated: [reason]]

Second Portion of Duodenum Position

• Pancreas—uncinate/head: [Normal / Abnormal: [descriptor] / Not evaluated: [reason]]
• Major ampulla region: [Normal / Abnormal: [descriptor] / Not evaluated: [reason]]
• Left adrenal: [Normal / Suspicious: [descriptor] / Not evaluated: [reason]] (Include when staging malignancy.)
• Regional lymph nodes: [None identified / Present: [station, size, characteristics] / Not evaluated: [reason]]
• Other: [Findings / Not evaluated: [reason]]

Lesion(s)

(Include this section only if one or more lesions are identified. Create a separate subsection for each lesion and cross-reference with tissue acquisition targets.)

Lesion [#]

• Anatomic location: [Organ; subregion]
• Size: [Length × Width × Height in mm] (Use three dimensions if feasible.)
• Sonographic features: [Echogenicity; homogeneity; solid vs cystic; calcifications; internal features (septations, mural nodules); vascularity on Doppler]
• Borders: [Well-defined / Poorly defined / Infiltrative]
• Relationship to adjacent structures: [Ductal dilation; vessel contact/abutment/encasement (name vessels); adjacent organ involvement suspected]
• Regional lymph nodes: [None / Suspicious: [station, short axis size, shape, border, echogenicity]; Sampled: [Yes / No]]
• EUS-based staging (if applicable): [T#: rationale]; [N#: rationale]; [M (limited by EUS): findings/limitations] (Use "EUS stage" terminology; note limitations for distant disease.)

(Add additional lesion subsections as needed.)

EUS-Guided Tissue Acquisition

(Include this section only if FNA or FNB was performed.)

Target [#] (linked to Lesion [#])

• Anatomic target and route: [Organ/subregion]; [Transgastric / Transduodenal / Transesophageal]
• Needle type and gauge: [FNA / FNB], [Gauge]
• Doppler: [Used to confirm no intervening vessels / Not used]
• Suction technique: [None / Slow-pull / Syringe suction]
• Number of passes: [# / Not recorded]
• ROSE: [Available / Not available]; [Preliminary adequacy impression if provided]
• Specimen handling: [Slides/smears; Cell block; Core in formalin; Flow cytometry; Cultures; Molecular studies] (List those submitted.)
• Cyst aspiration details (if applicable): Volume: [mL]; Fluid appearance: [Clear / Mucinous / Bloody / Turbid]; Tests ordered: [CEA, amylase, cytology, others]
• Immediate sampling-related events: [None / Event type; interventions; outcome]

(Add additional target subsections as needed.)

Adverse Events

[No intraprocedural adverse events / Adverse event occurred: [Type (bleeding / perforation / infection concern / cardiopulmonary event / pancreatitis concern)]; Severity: [descriptor]; Interventions: [descriptor]; Outcome at procedure end: [descriptor]]

Impression

• [Primary diagnosis or differential based on EUS findings]
• [EUS-based staging summary] (If applicable; clearly label as EUS-based and preliminary pending pathology.)
• [Examination completeness statement]
• [Pathology status] (e.g., Specimens obtained; pathology pending.)
• [Key pertinent negatives relevant to the indication] (e.g., no suspicious lymphadenopathy, no left adrenal involvement.)

Recommendations

• Pathology follow-up: [Await pathology; responsible team/person to contact patient; timeframe]
• Next steps: [Referral to surgical oncology / medical oncology / hepatobiliary surgery; timing] (If applicable.)
• If non-diagnostic: [Plan for repeat EUS-FNB or alternative biopsy approach; who will arrange] (If applicable.)
• Antithrombotic resumption: [Agent; when to resume; bridging plan] (If applicable.)
• Results communication: [Where specimens sent; who will review results; who will communicate to patient and referring clinician]

(Omit sections that do not apply—for example, omit EUS-Guided Tissue Acquisition if no sampling was performed. For clinically important items not assessed or not performed, explicitly state "Not evaluated" or "Not performed" with a brief reason rather than leaving blank. Do not infer normal for unexamined regions.)