Patient Data
EXAMPLE REPORTING TEMPLATE WITH CHECKLIST:
LOWER CHEST: Lung bases are clear. No pleural or pericardial effusion
Lung bases
Pleural effusion
Pericardial effusion
LIVER AND BILIARY: Normal liver morphology and enhancement. No masses. Normal gallbladder morphology. Normal caliber intrahepatic and common bile ducts.
Morphology
Enhancement
Masses
Vasculature
Gallbladder
Intrahepatic ducts
Common bile duct
PANCREAS: Normal morphology and enhancement. No ductal dilation or masses. No peripancreatic fluid.
Morphology
Enhancement
Lesions
Ductal dilation/anatomy
SPLEEN: Normal size and enhancement
Size
Enhancement
Lesions
ADRENALS: Normal morphology. No masses.
Morphology
Masses
KIDNEYS, URETERS, AND BLADDER: Normal renal size, morphology, and enhancement. No solid masses. No urolithiasis or hydronephrosis. Normal bladder wall thickness and enhancement.
Morphology
Enhancement
Masses
Stones
Collecting system
Ureters
Bladder
GI TRACT AND PERITONEUM: Normal morphology of the stomach and duodenum. Normal caliber small and large bowel. Normal appendix. No ascites.
Acute findings (SBO, appy, diverticulitis, enteritis, colitis, appendagitis, etc)
Distal esophagus and gastroesophageal junction
Stomach
Duodenum
Small and large bowel caliber, wall thickness, enhancement
Hernias (ventral, umbilical, spigellian, parastomal, lumbar, inguinal, femoral, obturator, sciatic)
Fluid collections
Free fluid
Free air
Peritoneal or omental implants
VASCULATURE: Portal, splenic, and superior mesenteric veins are patent. Visceral arteries are patent. No abdominal aortic aneurysm.
Portal, splenic, superior mesenteric veins
IVC
Abdominal aorta
Visceral arteries (celiac, splenic, common hepatic, renal, SMA, IMA)
Iliac, pelvic, and femoral arteries and veins
LYMPH NODES: No adenopathy.
Lower chest
Upper abdomen (gastrohepatic ligament, celiac, portocaval, porta hepatis)
Retroperitoneum
Mesentery
Pelvis (inguinal, mesorectal, sidewall)
Inguinal
REPRODUCTIVE ORGANS: Normal size and contours of the prostate and seminal vesicles.
Prostate
Seminal vesicles
Spermatic cord
Imaged scrotum and penis
Uterus present. No adnexal mass.
Uterus
Fallopian tubes
Ovaries
Cervix
Vagina
MUSCULOSKELETAL: No aggressive osseous lesion. No body wall masses.
Aggressive lesions
Benign lesions
Fractures
Vertebral body heights
Degenerative disease
Musculature and subcutaneous tissues
IMPRESSION:
Same study without annotations.
Case Discussion
A few comments about the scan:
- this is a CT of the Abdomen and Pelvis, Enterography protocol
- this is a higher quality study than a standard CT. It is performed with a higher radiation dose and larger dose of IV contrast, which helps to evaluate subtle areas of bowel inflammation.
- the slice thickness is 2.5 mm. This provides an excellent look at the large and small bowel enhancement and vasculature, and also the solid organs.
- this patient has a good deal of intrabdominal fat, which separates and surrounds structures, helping to see/differentiate better than in a thinner patient.
- this patient does have hepatic steatosis and a tiny gallstone or cholesterol polyp. The study is otherwise normal.