Lung Studies
SYNOPTIC - STRUCTURED REPORT - KEY ELEMENTS
- STRUCTURED TEMPLATES
The written report is the final product of the Nuclear Medicine consultation. Reports must contain specific information to identify the patient, the specific procedure, indications for the examination, radiopharmaceutical used and activity administered, route of administration, interval between tracer administration and imaging, succinct technical information about data acquisition and processing (especially the use and dose of additional drugs such as adenosine, CCK, morphine, lasix, etc), specific image and data analysis findings, and a conclusion.
The report should be concise, clear and specific. Standard anatomic designations and physiologic descriptors should be used. Jargon terms, such as "defect" or "photopenia", should not appear in the report. When possible, lesions should be specifically enumerated, physical size measured, and uptake quantified. When lesions are very numerous, the major areas of involvement should be specifically identified. When previous examinations are available, the improvement, progression or stability of disease should be identified. Examples of specific reports are contained with a description of each of the imaging procedures.
- GENERAL STRUCTURE
The following elements should be included in all reports:
Patient identifier: Name, gender, birth date, medical record number
Date procedure started and date reported
Procedure Title
Indication: Brief statement of clinical problem and question to be answered
Technical factors: Radiopharmaceutical, dose, route of administration, type of scan, interval between injection and imaging, interventions
Reference to prior examination of the same type
Reference to other procedures
Findings: Address clinical question first.
Interpretation: As definitive as possible and avoid repetition of findings.
- LUNG PERFUSION SPECT/CT
Clinical statement: A 62 year old man with metastatic prostate cancer and sudden onset of left pleuritic chest pain, for evaluation of possible pulmonary embolism.
Comparison: None
Correlation: CT scan of the chest performed [DATE]
Technique: Following non-contrast low dose CT, [XX] mCi 99mTc-MAA was injected intravenously. SPECT images were obtained.
Findings:
SPECT/CT: There are multiple segmental regions of decreased perfusion involving the right middle lobe and left lower lobe seen on both the planar and SPECT images. The CT scan demonstrates well aerated lung in these regions.
Impression: High probability of pulmonary embolism.
- LUNG VENTILATION / PERFUSION
Clinical statement: A 62 year old man with metastatic prostate cancer and sudden onset of left pleuritic chest pain, for evaluation of possible pulmonary embolism.
Comparison: None
Correlation: Portable chest x-ray performed [date]
Technique: Following inhalation of 99mTc-DTPA aerosol, images of the chest were recorded in the anterior, posterior as well as left and right anterior and posterior oblique views. Following intravenous injection of [XX] mCi 99mTc-MAA, images of the chest were recorded in the anterior, posterior as well as left and right anterior and posterior oblique views.
Findings:
Perfusion: There are multiple segmental regions of decreased perfusion involving the right middle lobe and left lower lobe seen on the planar images.
Ventilation: Ventilation is normal.
Chest X-ray: The chest film demonstrates well aerated lung in the areas of decreased perfusion.
Impression: High probability of pulmonary embolism.
- QUANTITATIVE VENTILATION & PERFUSION SCAN
Clinical statement: 70 year old woman with right lower lobe lung mass, for possible resection.
Comparison: None
Correlation: None
Technique: Following inhalation of 99mTc-DTPA aerosol, images of the chest were recorded in the anterior, posterior as well as left and right lateral views. Following intravenous injection of [XX] mCi 99mTc-MAA, images of the chest were recorded in the anterior, posterior as well as left and right lateral views.
Findings: Quantitative analysis results:
Perfusion:
Right upper lung [xx] Left upper lung [xx]
Right mid lung [ xx] Left mid lung [xx]
Right lower lung [xx] Left lower lung [xx]
Right lung total [xx] Left lung total [xx]
Ventilation:
Right upper lung [xx] Left upper lung [xx]
Right mid lung [xx] Left mid lung [xx]
Right lower lung [xx] Left lower lung [xx]
Right lung total [xx] Left lung total [xx]
Impression: Quantitative lung scan as described above.