CT Scan Result Sample Template PDF Radiology CT Scan

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CT Scan Result Sample

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Uploaded by Driza Esparagoza on May 27, 2019

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Ct scan result sample template

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May 27, 2019

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Ct Scan Result sample template COMPUTED TOMOGRAPHY
BRAIN-PLAIN

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PATIENT’S NAME (Last, First, Middle Name) DATE/TIME OF EXAM
Dalizon, Joseph Rapada s 4/23/2019 10:03 AM
PIN BIRTHDATE AGE GENDER ROOM/BED REQUESTING PHYSICIAN
Available
1411148899 Formats
3/18/1969 50Y 1M M OPD .

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HISTORY: Motorcycle vehicular accident

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COMPARISON: None

TECHNIQUE: Non-contrast axial 256-multislice CT scan of the brain was done using 3 x 1.5 mm

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slices. No contrast given as per request.

FINDINGS:
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There is no evidence of acute intracranial hemorrhage or territorial infarct. No discrete mass noted.

Gray-white matter differentiation is preserved.


Midline structures are in place.

The ventricles are normal in size and configuration. The cisterns and sulci are not effaced.

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The cavernous sinuses are fairly symmetrical. The sella and suprasellar regions are intact. The brainstem
and cerebellum are intact.

Small mucosal nodularity is noted in the LEFT sphenoid which may relate to mucous retention cyst or polyp.
Did youof find
The rest this document
the visualized useful?
paranasal sinuses and mastoid air cells are clear.

No discrete calvarial fracture. Minimal soft tissue swelling is observed in the LEFT parietal region.

IMPRESSION:

No acute intracranial hemorrhage and discrete calvarial fracture

Minimal soft tissue swelling, LEFT parietal region


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Julie Ann L. Jaca, MD Cherilyn R. Aquino, MD


(RESIDENT) (RADIOLOGIST)

OR/CI # 0069201904000916 VALIDATION DATE & TIME: 4/23/2019 11:11:38 AM


ACCESSION NO.: QCCT1950089 14648 Page 1 of 2
279 E. Rodriguez Sr. Ave., Quezon City, Tel. No.: (02) 723-0101 / 723-0301

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COMPUTED TOMOGRAPHY
BRAIN-PLAIN

PATIENT’S NAME (Last, First, Middle Name) DATE/TIME OF EXAM


Dalizon, Joseph Rapada s 4/23/2019 10:03 AM
PIN BIRTHDATE AGE GENDER ROOM/BED REQUESTING PHYSICIAN
1411148899 3/18/1969 50Y 1M M OPD .

This radiologic interpretation is only a part of the overall assessment of a patient's condition. It must be
correlated with the clinical, laboratory and other ancillary parameters for a comprehensive analysis.
Therefore, radiology reports are best explained by the attending physician of the patient.

Julie Ann L. Jaca, MD Cherilyn R. Aquino, MD


(RESIDENT) (RADIOLOGIST)

OR/CI # 0069201904000916 VALIDATION DATE & TIME: 4/23/2019 11:11:38 AM


ACCESSION NO.: QCCT1950089 14648 Page 2 of 2
279 E. Rodriguez Sr. Ave., Quezon City, Tel. No.: (02) 723-0101 / 723-0301

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