CT Scan Report

CT Scan Report: - Body Parts: [region of the body scanned] (Only include if explicitly mentioned in the transcript.) Clinical Information: - Indication: [reason for CT scan, clinical symptoms, or diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) - History: [relevant medical history, previous imaging studies, surgeries, or known diagnoses such as TB, HIV, malignancy, or trauma] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) Technique: - [description of the CT scan technique, including type of scan (e.g. non-contrast, contrast-enhanced), whether oral or IV contrast was used, and any specific protocol followed based on South African public or private sector resources] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) Findings: - [detailed description of the findings from the CT scan, including any abnormalities such as cavitation, lymphadenopathy, effusions, nodules, fractures, or signs of infection or malignancy. Include measurements, laterality, and any comparisons to previous imaging if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) Impression: - [summary of the key findings and clinical significance, e.g. "Findings consistent with post-TB fibrotic changes," "No evidence of acute intracranial pathology," or "Likely metastatic disease"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) Recommendations: - [suggested follow-up actions, such as referral to pulmonology, repeat imaging, TB work-up, biopsy, MRI, or specialist review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) Radiologist: - Name: [radiologist name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) - Date: [date of report] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise leave blank.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care. Use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output. Leave the relevant placeholder or section blank if it is not explicitly mentioned. Use as many full sentences as needed to capture all the relevant information from the transcript.)