CT Abdomen/Pelvis
Here's a practical template for reporting your preliminary findings when you're reviewing a CT abdomen/pelvis on your patient.
To keep your preliminary report brief, focus on the pertinent positive and negative findings.
Normal
Your job in the preliminary report is to detect emergencies:
Normal appendix.
No pancreatitis.
No diverticulitis.
No bowel obstruction.
No free air or free fluid.
No ureteral or renal stones.
No hydronephrosis or pyelonephritis.
No pericholecystic fluid or gallbladder wall thickening.
No abdominal or pelvic abscess.
No abdominal aortic aneurysm or dissection. The final report you receive from the radiologist is more comprehensive, which requires years of training - see How radiologists report the CT Abdomen/Pelvis.
Abnormal
Replace the appropriate part of your normal template with these phrases when you detect an abnormality.
Appendicitis
Acute, uncomplicated appendicitis
Uncomplicated appendicitis is appendicitis that hasn't ruptured. Here's how to look for appendicitis. Your preliminary report should include this phrase:
Acute, uncomplicated appendicitis, including [wall thickening], [dilated diameter], [periappendiceal fat stranding], and [appendicolith].Phrases in brackets are optional. Your case may have one or more of these findings.
Ruptured appendicitis
Ruptured appendicitis is appendicitis that has burst. Here's how to look for ruptured appendicitis. Your preliminary report should include a variation on this phrase:
Findings concerning for ruptured appendicitis, including [free air], [free fluid], [abscess], and [fat stranding] centered on the right lower quadrant and pelvis.Pancreatitis
Pancreatitis is inflammation of the pancreas. We've included the basic version, and other variations.
Uncomplicated pancreatitis
Findings concerning for pancreatitis, including [peripancreatic fat stranding], with uniform parenchymal enhancement.Necrotizing Pancreatitis
Necrotizing pancreatitis is a feared complication where portions of the pancreas die, resulting in hypo enhancement. Use this phrase:
Findings concerning for necrotizing pancreatitis, including [peripancreatic fat stranding], with areas of decreased pancreatic enhancement.
Pancreatic pseudocysts
Peripancreatic loculated fluid collections, consistent with pancreatic psuedocysts.Chronic pancreatitis
Pancreatic calcifications, consistent with chronic pancreatitis.Diverticulitis
Findings concerning for diverticulitis, including diverticulosis with [short-segment colonic wall thickening] and [pericolonic fat stranding], (with|without) [pericolic abscess].Small bowel obstruction
Findings concerning for small bowel obstruction, with dilated small bowel loops and transition point in the (insert location).Free air
Free intraperitoneal air concerning for bowel perforation.Free fluid
Free fluid in the (location)Ureteral stones
(Right|left) (proximal|mid|distal) (obstructing|nonobstructing) ureteral stone (with|without) (mild|moderate|severe) hydroureteronephrosis.Hydronephrosis
(Mild|moderate|severe) (left|right) hydronephrosis.Pyelonephritis
Concern for (right|left) pyelonephritis including [hetereogeneous enhancement] and [perinephric fat stranding].Acute cholecystitis
Findings concerning for acute cholecystitis, including [gallbladder wall thickening], [pericholecystic fluid], and [gallstones].Abscess
Rim-enhancing fluid collection in the (location), concerning for abscess.Aortic dissection
Intimal flap concerning for aortic dissection.