Difference between revisions of "Example reporting template"

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(Created page with '<pre> 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 screen...')
 
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The "Lung Nodule CT" report template below is shown as an example, and has not been finalized or approved.
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The [[report template guidelines]] explain the "markup" notation that has been defined for this effort. 
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 +
 
<pre>
 
<pre>
PROCEDURE: CT CHEST NON CONTRAST - NODULE PROTOCOL
+
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.}
+
  {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 nodules*].  
+
CLINICAL INDICATION: [Follow up lung nodule(s)*].  
  
COMPARISON: [None*].
+
COMPARISON: [<date> | None*].
  
TECHNIQUE: [Low-dose helical CT was acquired from lung apices to bases, and reconstructed at 2.5 mm every 1.25 mm, and 1.25 mm every 0.625 mm, without intravenous contrast.]  (DFOV = [ ] cm)
+
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:
 
FINDINGS:
Line 13: Line 21:
 
Nodules:  
 
Nodules:  
  
Nodule:  
+
    Nodule:  
Size: [# x # cm] {if size > 3cm, it's a "mass" and needs staging info}
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Size: [# x # cm]
Composition: [ solid | ground-glass | mixed | calcified | fatty | enhancing | cavitation ]
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            {if size > 3cm, it's a "mass" and needs staging info}
Calcification: [none* | benign pattern | indeterminate] {only if Composition = calcified}
+
Composition: [ solid | ground-glass | mixed | calcified  
Location: {lung/lobe/segment}
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                          | fatty | enhancing | cavitary ]
Image location: series # image #
+
Calcification: [none* | benign pattern | indeterminate]  
 
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            {only if Composition = calcified}
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Location: [ ]  {lung/lobe/segment}
 +
Image location: series [#] image [#]
 +
 
Other lung findings: [ ]
 
Other lung findings: [ ]
 
 
 +
Airway: [Normal*]
  
Airway: [Unremarkable.]
+
Pleura: [No pleural effusion, thickening, or pneumothorax]
  
Pleura: [No pleural effusion, thickening or pneumothorax.]
+
Thoracic aorta and great vessels: [Normal in diameter]
  
Thoracic aorta and great vessels: [<Normal in diameter.>]
+
Pulmonary arteries: [Normal*]
  
Pulmonary arteries: [<Normal.>]
+
Heart and pericardium: [Normal*]
  
Heart and pericardium: [<Unremarkable.>]
+
Lymph nodes: [No enlarged thoracic lymph nodes*]
  
Lymph nodes: [<No enlarged thoracic lymph nodes.>]
+
Thoracic spine: [Normal*]
  
Thoracic spine: [Unremarkable, with normal thoracic vertebral body heights.]
+
Chest wall: [Normal*]
  
Chest wall: [Unremarkable.]
+
Visualized upper abdomen: [Normal*]
 
+
Visualized upper abdomen: [Unremarkable.]
+
  
  
 
IMPRESSION:
 
IMPRESSION:
  
1.  [< >].
+
1.  [ ]
 +
 
  
 +
Recommendations for Follow-up and Management of Indeterminate Lung Nodules
 +
Detected Incidentally on Nonscreening CT
  
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)
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Adapted from the Fleischner Society Statement on CT of Small Pulmonary Nodules
 +
(Radiology 2005;237:395-400)
  
Nodule    Low-Risk Patient     High-Risk Patient
+
Nodule    Low-Risk Patient       High-Risk Patient
 
  Size
 
  Size
< 4 mm   no follow up needed     follow up CT at 12 months
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< 4 mm     no follow up needed   follow up CT at 12 months
                                if unchanged, no follow up
+
                                  if unchanged, no follow up
  
 
4-8 mm      follow up CT at 6, 12 and 24 months
 
4-8 mm      follow up CT at 6, 12 and 24 months
 
               if no change, further follow up
 
               if no change, further follow up
  
> 8 mm   contrast enhanced CT, PET and/or biopsy, OR
+
> 8 mm     contrast enhanced CT, PET and/or biopsy, OR
        watchful waiting: follow up CT at 3, 9 & 24 months
+
          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
+
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
 
</pre>
 
</pre>

Latest revision as of 22:29, 11 June 2009

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