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Radiologist Template

CT Scan Report

A professional Radiologist template for healthcare professionals.
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Specialty

Radiologist

Used

29 times

Type

Note

Last edited

9/24/2024

Created by

Dafydd Ap Emyr

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About this template

This CT Scan Report template is designed for radiologists to document detailed findings from CT scans. It includes sections for clinical information, scan technique, findings, impressions, and recommendations. Radiologists can use this template to provide comprehensive reports for various body regions, aiding in diagnosis and treatment planning. Ideal for radiology departments, this template streamlines the reporting process, enhancing communication with referring clinicians.

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CT Scan Report: - Body Parts: Abdomen and Pelvis Clinical Information: - Indication: Abdominal pain and suspected appendicitis - History: Previous appendectomy, no prior imaging studies Technique: - A contrast-enhanced CT scan of the abdomen and pelvis was performed using a helical scanner. Oral and intravenous contrast were administered to enhance visualization. Findings: - The CT scan reveals a dilated appendix with surrounding fat stranding, consistent with appendicitis. No evidence of perforation or abscess formation. The liver, spleen, pancreas, and kidneys appear normal. No free air or fluid in the abdomen. Impression: - Findings are consistent with acute appendicitis. No complications observed. Recommendations: - Surgical consultation for appendectomy is recommended. No additional imaging is necessary at this time. Radiologist: - Name: Dr. Dafydd Ap Emyr - Date: September 24, 2024

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