CT Report Composer
CT Cranial - Standard
CT Cranial - JNO
CT Cranial - MRQC
CT Cranial (Young) - JNO
CT Cranial - JJM
CT Abdomen - Standard
Study
Clinical data (required)
Non-enhanced
Contrast-enhanced
Comparison
None
Non-enhanced cranial CT scan
Contrast-enhanced cranial CT scan
Cranial CT angiogram
Date
Infarct
Present
Age
Acute
Subacute
Chronic
Location
Loss of grey-to-white matter differentiation
Ex vacuo dilatation
Dilatation of the
Hemorrhage
Present
Location
Size (cm)
×
×
—
cc (A × B × C × 0.524)
Age
Acute
Subacute
Chronic
Perilesional hypodensity (vasogenic edema)
Intraventricular extension
Lateral ventricle
Left
Right
Bilateral
Third ventricle
Fourth ventricle
Resultant ventricular dilatation
none
mild
moderate
marked
Mass effect
Effacement of adjacent cortical sulci
Compression of
mild
moderate
marked
Midline shift
Rightward
Leftward
Uncal herniation
Right
Left
Enhancement
No undue leptomeningeal or parenchymal enhancement
Old lacunar infarcts
Old lacunar infarcts
none
single
Few
Several
Multiple
Chronic microvascular white matter ischemic changes
Severity
none
Mild
Moderate
Severe
Present
Normal structures
Midline structures in place
Brainstem and cerebellum unremarkable
Brainstem intact
Cerebellum intact
Sulci, ventricles and cisterns
Unremarkable
Mildly prominent (cerebral)
Mildly prominent (cerebral and cerebellar)
Sella
Unremarkable
Partially empty
Physiologic calcifications
Bilateral lentiform and dentate nuclei
Atherosclerosis
Atherosclerotic vessel disease
Severity
Mild
Moderate
Extensive
Internal carotid arteries
bilateral
left
right
Vertebral arteries
bilateral
left
right
Sinuses, petromastoids, orbits and bones
Unremarkable
Sinusitis
Mastoiditis
Type
Acute
Chronic
Side
Aphakia / pseudophakia
Side
Study
Clinical information (required)
Technique
Triple Contrast
Rectal and IV
IV only
Plain CT scan of the whole abdomen
Comparison
None
Triple Contrast
Rectal and IV
IV only
Plain CT scan of the whole abdomen
Date
Liver
Mid hepatic length (cm)
Homogeneous parenchyma
Nodular contour
Mass
Dilated intrahepatic ducts
Dilated portal / hepatic veins
Portal vein
Hepatic veins
Gallbladder and biliary tree
Well-distended
Status
Partially contracted
Contracted
Thickened wall
Thickness
Pericholecystic fluid
Cholecystolithiasis
Biliary sludge
Dilated common bile duct
Diameter
Intraluminal densities
Size
Kidneys
Normal size
Good parenchymal enhancement
Poor enhancement side
No hydronephrosis or calculi
Hydronephrosis
Side
Degree
Mild
Moderate
Marked
Calculi
Hounsfield unit
Location
Size
Cyst
Quantity
Few
Several
Multiple
Type
Simple
Complex
Simple and Complex
Side
Right: largest in the
up to
Left: largest in the
up to
Pelvic organs
Omit
Male (prostate)
Female (uterus and adnexa)
Stomach
Well distended
Suboptimally distended
Aorta and iliac arteries
Wall calcifications
Severity
Minimal
Mild
Moderate
Extensive
Osseous structures
Osteophytes in the marginal endplates of the thoracolumbar spine
Quantity
Few
Several
Multiple
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