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


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
(calculated)

(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

Follow-Up


Options



MM/DD/YYYY

Lung-RADS


Impression

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


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