Radiologist Template

CTCA

A professional Radiologist template for healthcare professionals.

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Specialty

Radiologist

Used

7 times

Type

Note

Last edited

5/21/2025

Created by

Sook Yee Yong

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About this template

This CT Coronary Angiography (CTCA) template is designed for radiologists to document detailed findings from a CT scan of the coronary arteries. It includes sections for procedure details, contrast materials, medications, and any complications. The template also covers image quality, coronary angiogram findings, cardiac structures, extracardiac findings, and impressions. Radiologists can use this template to provide comprehensive reports that aid in diagnosing coronary artery disease. The template is optimized for use with Heidi, ensuring accurate and efficient documentation of CTCA results.

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CT Coronary Angiography Procedure: A CT coronary angiography was performed using a 64-slice CT scanner to evaluate the coronary arteries. Contrast: Iodinated contrast material was used to enhance the visualization of the coronary arteries. Medications: Intravenous beta-blockers were administered to lower the heart rate for optimal imaging. Complications: No complications were noted during the procedure. Image quality: The images obtained were of high quality with minimal artifacts, allowing for clear visualization of the coronary arteries. Coronary Angiogram: Left main: No significant stenosis observed. LAD: Mild plaque with no significant stenosis. Ramus intermedius: No abnormalities detected. LCX: No significant stenosis observed. RCA: Mild calcified plaque with no significant stenosis. Cardiac Structures: Left atrium: Normal size and function. Left ventricle: Normal size and function with an ejection fraction of 60%. Pulmonary arteries: No abnormalities detected. Pulmonary veins: Normal drainage pattern. Pericardium: No pericardial effusion noted. Cardiac valves: All valves appear normal with no regurgitation. Aorta: Normal caliber and course. Extracardiac Findings: Lungs and mediastinum appear normal with no significant findings. Impression: 1. Total calcium score: 150, indicating mild coronary artery disease. 2. Presence of mild coronary plaque without significant stenosis. 3. CAD-RADS score: 2, suggesting mild coronary artery disease. Recommendations: - Continue with current medical therapy for coronary artery disease. - Follow-up with a cardiologist for further management and lifestyle modifications.