Radiologist Chest CT Scan Template

**Scan date:** 11 2024 **Clinical information:** - Persistent cough and shortness of breath, ? malignancy **Prior imaging:** - Chest X-ray, 05 2024: Left lower lobe opacification. No prior CT for comparison. **Chest and thorax:** - Lungs: Multiple scattered, ill-defined nodules are noted bilaterally, largest in the right upper lobe measuring 12 x 10 mm. No obvious cavitation. Bronchial wall thickening noted in the lower lobes. Normal parenchymal density overall. - Pleura: Small left pleural effusion, estimated at 50 ml. No pleural thickening or nodularity. - Mediastinum: Subcentimetre mediastinal lymph nodes, level 2R and 4R, largest measuring 8 mm. No significant adenopathy. - Heart: Normal cardiac size. Coronary arteries show moderate calcification. - Aorta: Normal calibre and course of the thoracic aorta. - Other: Normal bony thorax and soft tissues of the chest wall. **Abdomen and pelvis:** - Liver, spleen, pancreas, common bile duct and gallbladder findings: Liver is normal in size and attenuation. No focal lesions. Gallbladder is unremarkable. Spleen and pancreas appear normal. Common bile duct is not dilated. - Adrenal glands findings: Adrenal glands are normal in size and morphology bilaterally. - Kidneys findings including any cysts, masses, stones, or calculi: Both kidneys are normal in size and demonstrate normal enhancement. A simple cortical cyst is noted in the right kidney measuring 15 mm, Bosniak I. No evidence of hydronephrosis or calculi. - Ureters and urinary bladder findings: Ureters are not dilated. Urinary bladder is adequately distended and unremarkable. - Colon, rectum, sigmoid, descending colon, transverse colon, ascending colon findings including pericolic fat stranding, lymph nodes, fluid or adenopathy: No pericolic fat stranding. No suspicious lymph nodes or fluid. The colon appears unremarkable. - Large bowel condition: Normal. - Terminal ileum, ileocaecal valve, and appendix findings: Appendix not clearly visualised due to colonic contents. Terminal ileum and ileocaecal valve appear normal. - Small bowel pathology presence or absence: No evidence of small bowel pathology. - Stomach contents and any abnormalities: Stomach contains fluid and gas, otherwise normal. - Peritoneal, retroperitoneal or pelvic lymph nodes presence or absence: No significant peritoneal, retroperitoneal, or pelvic lymphadenopathy. - Ascites presence or absence: No ascites. - Uterus, adnexa or gynaecological structures findings: Uterus and adnexa appear normal. **Bones, joints and soft tissues:** - Malignant bony abnormalities or metastases: No aggressive bony lesions or definite metastases. - Incidental findings such as degenerative disease: Mild degenerative changes noted in the thoracic and lumbar spine. - Subcutaneous or other soft tissue abnormalities including breast pathology: No suspicious subcutaneous or soft tissue abnormalities. **Conclusion:** - **ALERT: COPY REPORT TO REFERRING CLINICIAN** - Bilateral pulmonary nodules, ? metastatic disease vs inflammatory/granulomatous process. Further characterisation recommended. - Small left pleural effusion. - Moderate coronary artery calcification. "Please note that endoluminal upper and lower GI malignancy along with bladder malignancy cannot be excluded and direct visualisation should be considered in order to fully exclude malignancy from the imaged volume." - Recommend clinical correlation and consider PET-CT for further evaluation of pulmonary nodules. Repeat CT chest in 3 months for follow-up if clinically indicated and no further intervention planned. Incidental moderate coronary artery calcification demonstrated. If the patient has associated symptoms of angina, recommend management as per chest pain guidelines, including cardiology referral if appropriate. If the patient is asymptomatic, routine cardiology referral not required, GP and/or referring clinician to consider reviewing modifiable cardiovascular risk factors and managing as per guidelines for primary prevention.