Radiologist Template

CECT Abdomen (Normal/Abnormal)

A professional Radiologist template for healthcare professionals.

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Specialty

Radiologist

Used

5 times

Type

Note

Last edited

12/12/2024

Created by

Siddharth Krishnakumar

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About this template

The CECT Abdomen (Normal/Abnormal) template is a comprehensive tool for documenting CT scan findings of the abdomen, used by specialists such as radiologists. This template ensures detailed reporting of abdominal structures, including the liver, gall bladder, pancreas, spleen, kidneys, and more. It is designed to capture both normal and abnormal findings, providing a thorough impression of the patient's abdominal health. When used with Heidi, this template facilitates accurate and efficient documentation, enhancing clinical reporting and patient care. Ideal for those seeking to create detailed CT abdomen reports.

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CT Abdomen (Plain & Contrast) Report Technique: CT scan of the abdomen has been done with administration of oral and intravenous contrast media. Findings: Liver shows normal size, shape and attenuation. No mass lesion or calcification in the hepatic parenchyma. The porta hepatis is normal. No IHBR or CBD dilatation. Gall bladder reveals normal lumen and walls with normal size and shape. No mass lesion, calcification or stone is seen within the lumen. Pancreas appears normal in size and architecture. Pancreatic duct is not dilated. Spleen is normal in size and architecture. No focal lesion. Both kidneys reveal normal in size, shape, position and attenuation. No mass lesion, calcification or stone is seen in the renal parenchyma or collecting systems on both sides. No signs of obstructive uropathy are detected. Both adrenals are visualized normally. The IVC, aorta and portal vein are within normal position and caliber. No evidence of retroperitoneal lymphadenopathy or ascites. The visible parts of the bowel loops show no obvious mass lesions or wall thickening. Appendix appears normal. Urinary bladder reveals normal lumen and walls. No vesical calculi, wall thickening or mass lesion. Prostate appears normal. Visualized osseous structures appear normal. No lytic or sclerotic bony lesion. The extra-abdominal and paraspinal soft tissues are normal. Lung bases are clear. No basal pleural effusion. Impression: No significant abnormality is seen in present examination.