An approach that correctly identifies the protocol, considers pulmonary and mediastinal findings together, and prioritizes incidental findings by clinical importance.
REPORTING SYSTEMATICS / CHEST
An approach that correctly identifies the protocol, considers pulmonary and mediastinal findings together, and prioritizes incidental findings by clinical importance.
Chest CT is not a single examination. Standard noncontrast CT, contrast-enhanced chest CT, CT pulmonary angiography, aortic protocols, high-resolution CT, and low-dose screening studies answer different clinical questions. Before writing the report, confirm the protocol, contrast phase, inspiratory and expiratory acquisitions, section thickness, and reconstructions, and determine whether they are appropriate for the clinical question.
Assuming the wrong protocol may produce a report that fails to answer the clinical question even when normal anatomy is described correctly. For example, evaluation of the pulmonary arteries on a routine venous-phase chest CT should not be expressed with the same level of certainty as on a properly performed CT pulmonary angiogram.
| One pass is not enough Reviewing a chest CT only on lung windows or only in the axial plane may lead to missed mediastinal, vascular, osseous, and upper abdominal findings. At minimum, lung, soft-tissue, and bone windows and coronal and sagittal reconstructions should be examined in separate passes. |
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A nodule report should state the side, lobe, and, when possible, segment; solid, subsolid, or ground-glass character; measurement in an appropriate plane; margin characteristics; calcification or fat content; and interval change. When multiple nodules are present, prioritize the dominant or most suspicious lesion that will drive management.
Follow-up recommendations vary according to patient age, malignancy history, immune status, risk profile, nodule type, and current guidelines. Therefore, use recommendations verified against the patient context and the current guideline adopted by the institution rather than a fixed automatic sentence.
Terms such as ground-glass opacity, reticulation, consolidation, or centrilobular nodules may not be sufficient by themselves. Describe upper-versus-lower lung, central-versus-peripheral, peribronchovascular-versus-subpleural, focal-versus-diffuse, and symmetric-versus-asymmetric distribution together with features such as volume loss, traction bronchiectasis, honeycombing, or air trapping.
The report should not become a dictionary of patterns. Details that do not answer the clinical question should be shortened, while interpretations such as infection, edema, interstitial lung disease, or malignancy should be provided in the impression with appropriate clinical context and level of confidence.
Protocol-specific sections—for example, pulmonary arteries or interstitial lung disease—should be added separately:
| INDICATION: [Clinical question] COMPARISON: [Date and examination] TECHNIQUE: [Contrast status/phase, sections, reconstructions, inspiration/expiration, limitations] FINDINGS: Lungs and airways: [Pattern, distribution, nodule, airway findings] Pleura: [Effusion, pneumothorax, thickening] Mediastinum and hila: [Lymph node/mass/esophagus] Heart and pericardium: [Findings within examination scope] Great vessels: [Assessment permitted by the protocol] Chest wall and bones: [Important findings] Upper abdomen: [Important findings on included images] IMPRESSION: 1. [Primary thoracic finding answering the clinical question] 2. [Second important finding or interval change] 3. [Recommendation appropriate to guidelines and patient context, if needed] |
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Indication-specific messages should come first: findings that establish response or progression in oncologic follow-up, new parenchymal abnormalities when infection is suspected, or embolus location and signs of right-heart strain on a pulmonary embolism protocol. Incidental chronic changes should not obscure the primary question.
For an indeterminate finding, briefly state the level of probability and what additional information could help distinguish the possibilities. Rather than ending the report with a long, uncontrolled differential list, provide the few most likely options and note the need for clinical-radiologic correlation.
Are the protocol and contrast phase correctly documented? Were lung, soft-tissue, and bone windows reviewed separately? Were all lobes and airways surveyed? Were the pleura, lymph nodes, heart and pericardium, great vessels, and upper abdomen assessed? Are nodule or lesion measurements comparable with prior examinations? Does the impression directly answer the indication?
Este contenido es educativo y no constituye asesoramiento médico específico para un paciente. Antes de firmar, el médico debe verificar y adaptar cada frase, plantilla, resultado de clasificación y recomendación teniendo en cuenta todas las imágenes, el contexto clínico, las guías vigentes y el protocolo del centro.
Open an examination-specific framework in RadPhrases, adapt it to the findings, and verify it before signing.
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