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Diagnostic Radiologist
30-45 minutes

Contrast-Enhanced CT of the Abdomen (Normal/Abnormal) Template

The CECT Abdomen (Normal/Abnormal) template by s10.ai is an all-encompassing resource for documenting CT scan results of the abdomen, tailored for use by radiologists and other specialists. This template guarantees meticulous reporting of abdominal structures such as the liver, gall bladder, pancreas, spleen, and kidneys, among others. It is crafted to document both normal and abnormal findings, offering a comprehensive overview of the patient's abdominal health. When integrated with s10.ai, this template streamlines precise and efficient documentation, significantly enhancing clinical reporting and patient care. Perfect for clinicians aiming to produce detailed CT abdomen reports.

4,559 uses
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Dr. Emily Thompson
Template Structure

Organized sections for comprehensive clinical documentation

CT Abdomen (Plain & Contrast) Evaluation
Technique:
A CT scan of the abdomen was performed with the use of oral and intravenous contrast agents.
Findings:
[Describe any liver findings in detail] (use "Liver shows normal size, shape and attenuation. No mass lesion or calcification in the hepatic parenchyma. The porta hepatis is normal. No IHBR or CBD dilatation." if no abnormalities in liver, porta hepatis and CBD mentioned. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any gall bladder findings] (use "Gall bladder reveals normal lumen and walls with normal size and shape. No mass lesion, calcification or stone is seen within the lumen." if no abnormalities mentioned. If any abnormalities are mentioned edit this sentence appropriately.)
[Describe in detail any pancreas findings] (use "Pancreas appears normal in size and architecture. Pancreatic duct is not dilated." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any spleen findings] (use "Spleen is normal in size and architecture. No focal lesion." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any kidney findings] (use "Both kidneys reveal normal in size, shape, position and attenuation. No mass lesion, calcification or stone is seen in the renal parenchyma or collecting systems on both sides. No signs of obstructive uropathy are detected." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any adrenal findings] (use "Both adrenals are visualized normally." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any findings related to IVC, aorta, or portal vein] (use "The IVC, aorta and portal vein are within normal position and caliber. No evidence of retroperitoneal lymphadenopathy or ascites." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any bowel loops findings] (use "The visible parts of the bowel loops show no obvious mass lesions or wall thickening. Appendix appears normal." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any urinary bladder findings] (use "Urinary bladder reveals normal lumen and walls. No vesical calculi, wall thickening or mass lesion." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any findings related to prostate (in males) or findings related to uterus and ovaries (in females)] (use "Prostate appears normal." for males or "Uterus and both ovaries appear normal. No adnexal pathology." for females, if no abnormalities are mentioned. )
[Describe in detail any findings related to osseous structures and soft tissues findings] (print "Visualized osseous structures appear normal. No lytic or sclerotic bony lesion. The extra-abdominal and paraspinal soft tissues are normal." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
[Describe in detail any findings in lung bases] (print "Lung bases are clear. No basal pleural effusion." if no abnormalities are specified. If any abnormalities are present edit this sentence appropriately)
(Note any additional findings or observations specific to this case)(use as many new lines/sentences to capture all the additional findings.)
Impression:
[List each impression or diagnosis with brief description] (print "No significant abnormality is seen in present examination" if impression is normal)
(Never come up with your own patient details, findings, diagnosis, impression, or plan - use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output, instead use the default normal sentence provided to you for that placeholder.)
(Do not use bullet points. Only write in complete sentences. For each placeholder, use as many sentences as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

CT Abdomen (Plain & Contrast) Report
Technique:
A CT scan of the abdomen was performed with the use of oral and intravenous contrast agents.
Findings:
The liver is of normal size, shape, and attenuation. There is no mass lesion or calcification in the hepatic tissue. The porta hepatis appears normal. There is no dilation of the intrahepatic bile ducts or common bile duct.
The gallbladder has a normal lumen and walls, with standard size and shape. There are no mass lesions, calcifications, or stones within the lumen.
The pancreas is normal in size and structure. The pancreatic duct is not dilated.
The spleen is of normal size and structure, with no focal lesions.
Both kidneys are normal in size, shape, position, and attenuation. There are no mass lesions, calcifications, or stones in the renal tissue or collecting systems on either side. No signs of obstructive uropathy are present.
Both adrenal glands are visualized normally.
The inferior vena cava, aorta, and portal vein are in normal position and caliber. There is no evidence of retroperitoneal lymphadenopathy or ascites.
The visible sections of the bowel loops show no apparent mass lesions or wall thickening. The appendix appears normal.
The urinary bladder has a normal lumen and walls. There are no vesical calculi, wall thickening, or mass lesions.
The prostate appears normal.
The visualized bony structures are normal. There are no lytic or sclerotic bone lesions. The extra-abdominal and paraspinal soft tissues are normal.
The lung bases are clear. There is no basal pleural effusion.
Impression:
No significant abnormalities are observed in the current examination.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The CT Abdomen (Plain & Contrast) Report template is an essential tool for radiologists and clinicians seeking comprehensive and detailed imaging assessments of the abdominal region. This template facilitates the systematic documentation of findings from CT scans performed with oral and intravenous contrast media, ensuring thorough evaluation of the liver, gall bladder, pancreas, spleen, kidneys, adrenals, and other critical structures such as the IVC, aorta, and portal vein. It also includes detailed sections for bowel loops, urinary bladder, reproductive organs, osseous structures, soft tissues, and lung bases. By adopting this template, healthcare professionals can ensure accurate and consistent reporting, aiding in the diagnosis and management of abdominal conditions. Explore this template to enhance your clinical documentation and improve patient care outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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