The "CT Abdomen and Pelvis Female with Contrast for Kidney Stone Protocol Negative" template is an essential tool for clinicians seeking precise diagnostic insights into renal and abdominal health. This comprehensive template is designed to enhance the detection and evaluation of kidney stones, providing detailed imaging that aids in ruling out nephrolithiasis and other potential abdominal pathologies. By utilizing contrast-enhanced CT imaging, healthcare professionals can achieve superior visualization of the urinary tract, ensuring accurate diagnosis and effective patient management. Adopting this protocol not only streamlines the diagnostic process but also optimizes patient outcomes by facilitating timely and informed clinical decisions. Explore the benefits of implementing this advanced imaging template to elevate your practice's diagnostic capabilities and improve patient care.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Radiology ReportPatient Name: John DoePatient ID: 123456Date of Birth: 01/15/1975Date of Examination: 10/20/2023Referring Physician: Dr. Jane SmithExamination: MRI of the Lumbar SpineClinical History:The patient presents with chronic lower back pain radiating to the left leg, with numbness and tingling. Symptoms have persisted for the past three months, with no significant relief from physical therapy or medication.Technique:MRI of the lumbar spine was performed using standard protocol sequences, including T1-weighted, T2-weighted, and STIR images in sagittal and axial planes.Findings:- Alignment: Normal lumbar lordosis is maintained. No evidence of spondylolisthesis.- Vertebral Bodies: Normal height and signal intensity of the vertebral bodies. No fractures or lesions identified.- Intervertebral Discs:- L3-L4: Mild disc bulge without significant canal or foraminal stenosis.- L4-L5: Moderate disc protrusion with mild central canal stenosis. Mild bilateral foraminal narrowing.- L5-S1: Large left paracentral disc herniation impinging on the left S1 nerve root, correlating with the patient's symptoms.- Spinal Canal and Neural Foramina: No significant spinal canal stenosis at other levels.- Soft Tissues: No abnormal paraspinal soft tissue masses.Impression:1. Large left paracentral disc herniation at L5-S1 impinging on the left S1 nerve root, correlating with the patient's clinical symptoms of left leg radiculopathy.2. Moderate disc protrusion at L4-L5 with mild central canal stenosis.3. Mild disc bulge at L3-L4 without significant stenosis.Recommendations:Consideration for neurosurgical consultation for potential intervention at L5-S1. Continued conservative management for L4-L5 and L3-L4 unless symptoms progress.Radiologist: Dr. Emily CarterDate of Report: 10/21/2023
Key advantages of using this template in clinical practice
Common questions about this template and its usage