Radiology Report Composer
CT Cranial - Standard
CT Cranial - MRQC
CT Cranial (Adult) - JNO
CT Cranial (Young) - JNO
CT Cranial - JJM
CT Cranial - GMM
CT Abdomen - Standard
CT Abdomen - Appendicitis
CT Chest - Standard
US KUB - Standard
Study
Clinical data (required)
Non-enhanced
Contrast-enhanced
Machine
64 MDCT
16 MDCT
Comparison
None
Non-enhanced cranial CT scan
Contrast-enhanced cranial CT scan
Cranial CT angiogram
Date
Infarct
Present
Age
Acute
Subacute
Chronic
Location
Loss of grey-to-white matter differentiation
Ex vacuo dilatation
Dilatation of the
Hemorrhage
Present
Location
Size (cm)
×
×
—
cc (A × B × C × 0.524)
Age
Acute
Subacute
Chronic
Perilesional hypodensity (vasogenic edema)
Intraventricular extension
Lateral ventricle
Left
Right
Bilateral
Third ventricle
Fourth ventricle
Resultant ventricular dilatation
none
mild
moderate
marked
Mass effect
Effacement of adjacent cortical sulci
Compression of
mild
moderate
marked
Midline shift
Rightward
Leftward
Uncal herniation
Right
Left
Extra-axial collection
Present
Type
Subdural hematoma
Epidural hematoma
Subarachnoid hemorrhage
Location
Thickness
Enhancement
No undue leptomeningeal or parenchymal enhancement
Old lacunar infarcts
Old lacunar infarcts
none
single
Few
Several
Multiple
Chronic microvascular white matter ischemic changes
Severity
none
Mild
Moderate
Severe
Present
Normal structures
Midline structures in place
Brainstem and cerebellum unremarkable
Brainstem intact
Cerebellum intact
Sulci, ventricles and cisterns
Unremarkable
Mildly prominent (cerebral)
Mildly prominent (cerebral and cerebellar)
Sella
Unremarkable
Partially empty
Physiologic calcifications
Bilateral lentiform and dentate nuclei
Atherosclerosis
Atherosclerotic vessel disease
Severity
Mild
Moderate
Extensive
Internal carotid arteries
bilateral
left
right
Vertebral arteries
bilateral
left
right
Calvarium, skull base and craniovertebral junction
Fracture
Location
Include normal atlanto-axial intervals and craniovertebral junction
Sinuses, petromastoids, orbits and bones
Sinusitis
Mastoiditis
Type
Acute
Chronic
Side
Aphakia / pseudophakia
Side
Study
Clinical information (required)
Technique
Triple Contrast
Rectal and IV
IV only
Plain CT scan of the whole abdomen
Comparison
None
Triple Contrast
Rectal and IV
IV only
Plain CT scan of the whole abdomen
Date
Appendix
Diameter (cm)
Dilated
Appendicolith
Periappendiceal fat stranding or fluid collection
Liver
Mid hepatic length (cm)
Heterogeneous parenchyma
Nodular contour
Mass
Dilated intrahepatic ducts
Dilated portal / hepatic veins
Portal vein
Hepatic veins
Gallbladder and biliary tree
Contracted
Status
Partially contracted
Contracted
Thickened wall
Thickness
Pericholecystic fluid
Cholecystolithiasis
Biliary sludge
Dilated common bile duct
Diameter
Intraluminal densities
Size
Pancreas
Atrophic or Enlarged
Size
Atrophic
Enlarged
Focal lesion
Location
Size
Dilated pancreatic duct
Diameter
Calcifications
Spleen
Enlarged
Craniocaudal length
Heterogeneous parenchyma
Focal lesion
Size
Calcified granuloma
Adrenal glands
Mass lesion
Side
Size
Thickening
Side
Kidneys and Urinary Bladder
Small or Enlarged
Size
Small
Enlarged
Poor parenchymal enhancement
Poor enhancement side
Hydronephrosis or calculi
Hydronephrosis
Side
Degree
Mild
Moderate
Marked
Calculi
Hounsfield unit
Location
Size
Cyst
Quantity
Few
Several
Multiple
Type
Simple
Complex
Simple and Complex
Side
Right: largest in the
up to
Left: largest in the
up to
Suboptimally distended
Wall thickening
Intravesical densities
Size
Pelvic organs
Omit
Male (prostate)
Female (uterus and adnexa)
Esophagus, Stomach, Small and Large bowels
Esophagus
Hiatal hernia
Distal esophageal wall thickening
Stomach
Suboptimally distended
Wall thickening
Location
Small and large bowels
Dilated bowel loops
Segment
Small bowel
Large bowel
Small and large bowels
Colonic wall thickening
Segment
Dilated appendix
Diameter
Colonic diverticulosis
Ascites
Amount
Mild
Moderate
Large
Pneumoperitoneum
Lymph nodes
Enlarged lymph nodes
Mesenteric
Retroperitoneal
Pelvic
Inguinal
Largest, short axis
Atherosclerosis
Wall calcifications
Severity
Minimal
Mild
Moderate
Extensive
Dilated abdominal aorta
Diameter
Osseous structures
Osteophytes in the marginal endplates of the thoracolumbar spine
Quantity
Few
Several
Multiple
Lytic lesion
Location
Blastic lesion
Location
Fracture
Location
Imaged lower thorax
Pleural effusion
Side
Amount
Small
Moderate
Large
Atelectatic / consolidative changes
Side
Pulmonary nodule
Location
Size
Cardiomegaly
Study
Clinical information (required)
Technique
Noncontrast and contrast enhanced
Contrast enhanced
Noncontrast
High resolution
Comparison
None
Noncontrast and contrast enhanced
Contrast enhanced
Noncontrast
High resolution
Date
Lungs and pleura
Pulmonary mass/nodule
Type
Non-calcified
Calcified
Location
Size
cm
Consolidation
Location
Pleural effusion
Side
Amount
Small
Moderate
Large
Right
Small
Moderate
Large
Left
Small
Moderate
Large
Airways and lymph nodes
Endobronchial lesion
Location
Enlarged lymph nodes
Location
Largest, short axis
cm
Heart and great vessels
Cardiomegaly
Pericardial effusion
Dilated thoracic aorta
Diameter
cm
Wall calcifications
Severity
Mild
Moderate
Marked
Aorta
Coronary arteries
Osseous structures
Osteophytes
Quantity
Few
Several
Multiple
Lytic lesion
Location
Blastic lesion
Location
Fracture
Location
Chest wall, breasts and axilla
Chest wall
Nodule/Mass
Size
cm
Fat stranding
Breasts
Surgically absent
Side
Mass
Location
Size
cm
Fat stranding densities
Calcifications
Location
Size
cm
Axilla
Enlarged lymph nodes
Side
Largest, short axis
cm
Thyroid and lower neck
Nodule/Mass
Location
Size
cm
Imaged upper abdomen
Renal cysts
Gallstones
Study
Clinical information (required)
Comparison
None
KUB ultrasound
KUB and prostate ultrasound
Whole abdominal ultrasound
CT stonogram
Whole abdominal CT scan
Date
Kidneys
Right (mm)
×
×
Left (mm)
×
×
Parenchymal thickness (mm)
Right
Left
Echogenicity
Normal
Increased
Cortico-medullary junctions
Distinct
Indistinct
Cortical cysts
Quantity
Single
Few
Several
Multiple
Type
Simple
Complex
Simple and complex
Side
Right: largest in the
×
×
mm
Left: largest in the
×
×
mm
Solid mass
Side
Right
Left
Location
Size
×
×
mm
Internal vascularity on color Doppler
Pelvocalyceal dilatation / fullness
Side
Degree
Fullness
Mild
Moderate
Marked
Proximal ureter also dilated
Lithiasis
Side
Right
Left
Location
Size
×
×
mm
Urinary bladder
Distension
Adequate
Suboptimal
Empty
Catheterized (Foley)
Measured
Void
Drain
Pre volume
cc
Wall thickness
mm
Irregular mucosal outline
Intraluminal echoes (debris)
Diverticulum
Wall
Size
×
×
mm
Post volume
cc
—
% residual (post ÷ pre)
Prostate
Include prostate
Approach
Transabdominal
Transrectal
Size (mm)
×
×
—
grams (L × T × W × 0.52 ÷ 1000; over 25 g is reported as prostatomegaly)
Parenchymal calcifications or Mass
Parenchymal calcifications
Quantity
Few
Several
Multiple
Mass
Size
mm
Intravesical extension
Cyst
Location
Size
×
×
mm
Incidental findings
Ascites
Amount
Trace
Minimal
Mild
Moderate
Large
Pleural effusion
Side
Increased hepatic echogenicity (fatty liver)
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