Example reporting template

From Reporting Wiki
Jump to: navigation, search

The "Lung Nodule CT" report template below is shown as an example, and has not been finalized or approved.

The report template guidelines explain the "markup" notation that has been defined for this effort.


PROCEDURE: CT CHEST NON-CONTRAST - NODULE PROTOCOL
  {Used for nodules less than 10 mm; generally fewer than 6 nodules; 
   not diffuse nodules;  or for sarcoma metastasis screening.}

CLINICAL INDICATION: [Follow up lung nodule(s)*]. 

COMPARISON: [<date> | None*].

TECHNIQUE: [Low-dose helical CT was acquired without intravenous contrast
from lung apices to bases, and reconstructed at 2.5 mm every 1.25 mm, 
and 1.25 mm every 0.625 mm.]  (DFOV = [ ] cm)

FINDINGS:

Nodules: 

    Nodule: 
	Size: [# x # cm]
            {if size > 3cm, it's a "mass" and needs staging info}
	Composition: [ solid | ground-glass | mixed | calcified 
                          | fatty | enhancing | cavitary ]
	Calcification: [none* | benign pattern | indeterminate] 
            {only if Composition = calcified}
	Location: [ ]   {lung/lobe/segment}
	Image location: series [#] image [#]
	
Other lung findings: [ ]		
		
Airway: [Normal*]

Pleura: [No pleural effusion, thickening, or pneumothorax]

Thoracic aorta and great vessels:  [Normal in diameter]

Pulmonary arteries: [Normal*]

Heart and pericardium: [Normal*]

Lymph nodes: [No enlarged thoracic lymph nodes*]

Thoracic spine: [Normal*]

Chest wall: [Normal*]

Visualized upper abdomen: [Normal*]


IMPRESSION:

1.  [ ]


Recommendations for Follow-up and Management of Indeterminate Lung Nodules 
Detected Incidentally on Nonscreening CT 

Adapted from the Fleischner Society Statement on CT of Small Pulmonary Nodules
(Radiology 2005;237:395-400)

Nodule     Low-Risk Patient       High-Risk Patient
 Size
< 4 mm     no follow up needed    follow up CT at 12 months
                                  if unchanged, no follow up

4-8 mm       follow up CT at 6, 12 and 24 months
              if no change, further follow up

> 8 mm     contrast enhanced CT, PET and/or biopsy, OR
           watchful waiting: follow up CT at 3, 9 & 24 months


Notes: diameter = average width; high risk is defined as a history of smoking
or other know risk factors for lung cancer; low risk is defined as minimal or 
absent history of smoking or other known risk factors; caveat: nodules with a 
ground glass component may require longer follow up to exclude indolent 
adenocarcinoma