How to read a CT of the abdomen and pelvis

EXAMPLE REPORTING TEMPLATE WITH CHECKLIST:

LOWER CHEST: Lung bases are clear. No pleural or pericardial effusion

• Lung bases

• Pleural effusion

• Pericardial effusion

LIVER AND BILIARY: Normal liver morphology and enhancement. No masses. Normal gallbladder morphology. Normal caliber intrahepatic and common bile ducts.

• Morphology

• Enhancement

• Masses

• Vasculature

• Gallbladder

• Intrahepatic ducts

• Common bile duct

PANCREAS: Normal morphology and enhancement. No ductal dilation or masses. No peripancreatic fluid.

• Morphology

• Enhancement

• Lesions

• Ductal dilation/anatomy   

SPLEEN: Normal size and enhancement

• Size

• Enhancement

• Lesions

ADRENALS: Normal morphology. No masses.

• Morphology

• Masses

KIDNEYS, URETERS, AND BLADDER: Normal renal size, morphology, and enhancement. No solid masses. No urolithiasis or hydronephrosis. Normal bladder wall thickness and enhancement.

• Morphology

• Enhancement

• Masses

• Stones

• Collecting system

• Ureters

• Bladder

GI TRACT AND PERITONEUM: Normal morphology of the stomach and duodenum. Normal caliber small and large bowel. Normal appendix. No ascites.

• Acute findings (SBO, appy, diverticulitis, enteritis, colitis, appendagitis, etc)

• Distal esophagus and gastroesophageal junction

• Stomach

• Duodenum

• Small and large bowel caliber, wall thickness, enhancement

• Hernias (ventral, umbilical, spigellian, parastomal, lumbar, inguinal, femoral, obturator, sciatic)

• Fluid collections

• Free fluid

• Free air

• Peritoneal or omental implants

VASCULATURE: Portal, splenic, and superior mesenteric veins are patent. Visceral arteries are patent. No abdominal aortic aneurysm.

• Portal, splenic, superior mesenteric veins

• IVC

• Abdominal aorta

• Visceral arteries (celiac, splenic, common hepatic, renal, SMA, IMA)

• Iliac, pelvic, and femoral arteries and veins

LYMPH NODES: No adenopathy.

• Lower chest

• Upper abdomen (gastrohepatic ligament, celiac, portocaval, porta hepatis)

• Retroperitoneum

• Mesentery

• Pelvis (inguinal, mesorectal, sidewall)

• Inguinal

REPRODUCTIVE ORGANS: Normal size and contours of the prostate and seminal vesicles.

• Prostate

• Seminal vesicles

• Spermatic cord

• Imaged scrotum and penis

Uterus present. No adnexal mass.

• Uterus

• Fallopian tubes

• Ovaries

• Cervix

• Vagina

MUSCULOSKELETAL: No aggressive osseous lesion. No body wall masses.

• Aggressive lesions

• Benign lesions

• Fractures

• Vertebral body heights

• Degenerative disease

• Musculature and subcutaneous tissues

IMPRESSION:

Same study without annotations.