Chest Rotation Dictation Templates

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Lung Nodule Chest CT:

 

 

History:

Lung Nodules

Technique:

Noncontrast CT of the chest was performed.  Thin section and multiplanar reformats provided for review.

Radiation Dose:
CTDI: [ ]

DLP:  [ ]

 

Recent Prior:

[ ]

Remote Prior

N/A

 

Findings:

 

Nodules (thin section imaging, Series [ ]):
Right Lung:

[ ]

Left Lung:

[ ]

 

Lung Parenchyma:

No airspace disease

Pleura:

No pleural process or pneumothorax.

Airways:
Patent.  Normal mural thickness.

 

Heart:

Normal size.  No pericardial effusion.

 

Mediastinum:
No adenopathy.

Axillae, Supraclavicular, and Paraesophageal Region
No adenopathy.

 

Thyroid:
The visualized portion is unremarkable.

Vascular:
Normal caliber thoracic aorta.

Normal caliber main pulmonary trunk.

 

Osseous Structures:

Unremarkable.

Soft Tissues:

Unremarkable.

 

Visualized Abdomen:

No abnormality seen.

Impression:

[ ]

 

 

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Lung Cancer Screening Protocol

 

History: 
Lung Cancer Screening Protocol

Technique: 
Transaxial CT imaging of the thorax was performed without contrast including thin sections.  A Low Dose Protocol was utilized.  Multiplanar datasets were constructed and submitted to PACS.

DLP:  []
CTDI:  []

Reference Exams: 
Prior Noncontrast CT Chest from [ ] .  
Index Study:  [N/A]

Findings:
Nodules (All measurements obtained on high resolution imaging series [4] and compared to prior thin section imaging series):
Right Lung:
[ ] mm [solid] nodule in the [ ] lobe, previously measuring [ ] mm.
Left Lung: 
[ ] mm [solid] nodule in the [ ] lobe, previously measuring [ ] mm.

Lung Parenchyma:  No airspace disease.  
Pleura: No effusion or pneumothorax.
Airways:  Patent.  No lesions.
Mediastinum:  No adenopathy.  
Vessels:  Normal caliber thoracic aorta at [] mm transaxial dimension.  Normal caliber pulmonary artery.
Heart:  Normal size.  No pericardial effusion.

Chest Wall:  Unremarkable.
Bones:  No focal lesions.  

Upper Abdomen:  Unremarkable.  

Impression:
LUNG-RADS CATEGORY: [ ]
Unremarkable study.

LUNG-RADS categories:
1. Negative
2. Negative with benign pulmonary findings
3. Positive/likely benign
4. Positive/suspicious for malignancy
5. Known cancer 

S-category refers to extra-pulmonary findings that will require follow-up but are not suspicious of lung cancer. 

 

Guidlines for follow up in PDF:

 

 

 

 

 

 

 

link to ACR site for addt'l guidelines:  http://www.acr.org/Quality-Safety/Resources/LungRADS