Sample, Sammy G ST0001

CT Evaluation Form 1234567890


Scan information

MM/DD/YYYY

Only select Baseline if there is no prior CT or there is a prior CT scan more than 3 years ago

MM/DD/YYYY 0 months since baseline
MM/DD/YYYY

Nodules

READ before completing the Nodule Grid

  • BASELINE: Include all nodules >= 6.0 mm in average diameter. Others are OPTIONAL.
  • ANNUAL REPEAT: include all NEW nodules >= 3.0 mm in average diameter.
  • For BASELINE CT, all nodules are new unless there is a CT more than 3 years earlier.
  • For BASELINE CT, the nodules will automatically be sorted with the largest non-calcified nodules with a solid component coming first.
  • Note: hilar masses and focal consolidation should be included in the nodule grid.
  • The same nodule ID will be used on all subsequent CT and other forms. NEW nodules, even if LARGER, must follow nodules already listed.
  • For nodules recommended for biopsy or antibiotics, list the reason in the comments field in the corresponding column.
If no nodules were detected, you may skip this section.

Emphysema/Coronary Calcifications



(calculated)

Other Abnormalities

RUL RML RLL LUL LLL

(focal - put in nodule grid)

(i.e. bronchial resection margin)

Early and Late Findings of Interstitial Lung Disease

RUL RML RLL LUL LLL
RUL RML RLL LUL LLL

(report if ovoid > 7 mm or if thymic shape with width > 1.3cm)

Lymph Nodes (w/o central fat)

Any enlarged or growing hilar or mediastinal lymph nodes
(short axis > 10mm)
(any size for para-esophageal)

View lymph node chart
8 th edition classification: CHEST 2017; 151: 193-203
Any calcified hilar or mediastinal lymph nodes
Abnormal axillary lymph nodes
Other Vascular Abnormalities
Esophageal
Hiatal Hernia
Other Mediastinal Masses
Right Breast
Right Breast Density Classification (BI-RADS)
Left Breast
Left Breast Density Classification (BI-RADS)
Gallbladder
Spleen
Liver
Pancreas
Adrenals
Kidneys

Impression

Annual repeat and follow-up CT scans should utilize the same low-dose protocol used for baseline low-dose CT scans.
Other Findings

Follow-Up


Options



MM/DD/YYYY

Lung-RADS



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