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<!-========================================================================= == Copyright (c) 2009, Radiological Society of North America, Inc. (RSNA) ALL RIGHTS RESERVED This file is part of the "RSNA Radiology Reporting Templates." The "RSNA Radiology Reporting Templates" are licensed without charge under the RSNA's license agreement (the "License"); you may not use this file except in compliance with the License. You may obtain a copy of the License at: http://reportingwiki.rsna.org/index.php?title=File:License.doc Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an "AS IS" BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied. See the License for the specific language governing permissions and limitations under the License. ========================================================================= == --> RSNA CCTA TEMPLATE Clinical Indication: [#] year old [woman |man] with coronary artery disease risk factors of [hyperlipidemia; hypertension; diabetes; autoimmune disease; prior MI; prior stroke; smoking history; family history of heart disease] presenting with [exertional angina; atypical chest pain; chronic chest pain; shortness of breath; arm pain; jaw pain; palpitations; ECG changes; prior abnormal single photon emission computed tomography study; prior abnormal echocardiogram; heart failure; cardiomyopathy; pre-surgical assessment] for evaluation of the presence of coronary artery disease. Comparison studies: [type; date] Imaging Technique: A [#]-slice multidetector computerized tomography coronary angiogram was obtained using [prospective | retrospective] ECG gating. [{only insert this sentence if retrospective ECG gating was used}ECG tube modulation [*was used to reduce the radiation exposure | was not used because of arrhythmia| was not used because of the need for systolic and diastolic imaging]. The coronary CT angiogram was performed with [#] mL of [type] contrast administered intravenously. Imaging was performed from the level of the [pulmonary artery bifurcation | carina] to the level of the hemidiaphragms. In order to provide better evaluation of the anatomy and disease process, advanced off-line 3-D post-processing techniques, including [multiplanar reconstruction; maximal intensity projections; curved reconstructions; and volume rendering] were performed. {If a calcium score has been performed, the technique and results should also be included in the CT angiogram report}. Medication administered in preparation for the examination: ß- blocker: [[#] mg [type] p.o. x [#] doses]; [[#] mg [type] IV x [#] doses] for heart rate/rhythm control [Calcium channel blocker: [#] mg [type] IV x [#] doses for heart rate/rhythm control] Nitroglycerin: [* 0.4] mg SL [*spray | tablet] for coronary vasodilation {Describe any pre-examination steroid preparation or Benadryl administration here for contrast allergy} Vital Signs: Before medication administration, the heart rate was [#] beats per minute and the blood pressure was [#] mm Hg. Upon discharge, the heart rate was [#] beats per minute and the blood pressure was [#] mm Hg. Procedure Complications/ Allergic reactions: [*none]. Radiation Dose: The CT dose index-volume was [#] mGy, and dose length product of the examination was [#] mGy-cm. Coronary CT Angiogram Quality: The overall quality of the CT angiographic examination is [excellent| good| fair | poor | nondiagnostic] and is limited by [poor arterial opacification; misregistration artifacts; patient motion; calcium blooming artifacts; metal artifact; arrhythmia]. Coronary Artery Angiogram Findings: Stenoses are reported as maximum percentage diameter stenosis. Stenosis grading is reported using the following scheme: Normal: no stenosis Mild: 1-49% stenosis Moderate: 50-70% stenosis Severe: >70% stenosis Occluded Dominance of the coronary artery system: [*right | left | co-dominant] with [*normal | anomalous] origins and course. Left Main: The left main is a [*normal | small] caliber vessel which gives rise to the [* LAD and circumflex arteries | LAD and circumflex arteries as well as a ramus intermedius artery {if this option is chosen, the qualities of the ramus intermedius branch need to be reported}]. The left main [has no stenosis | has mild stenosis | has moderate stenosis | has severe stenosis | is occluded | is nonevaluable] with [no | noncalcified | mixed | calcified] plaque. {If present, stents should be described by size (if known), type (if known), number, and segmental location. Any relation to the adjacent branch vessel ostium should be described. In addition, the stent should be described as patent, occluded, or stenosed. Any in-stent stenosis, fracture, or calcification should also be described} Left Anterior Descending Artery: The proximal left anterior descending artery and first diagonal branch [have no stenosis | have mild stenosis | have moderate stenosis | have severe stenosis | are occluded | are nonevaluable] with [no | noncalcified | mixed | calcified] plaque. The mid-distal LAD, D2 and D3 branches [have no stenosis | have mild stenosis | have moderate stenosis | have severe stenosis | are occluded | are nonevaluable] with [no | noncalcified | mixed | calcified] plaque. [There is a [short | long] [superficial | deep] myocardial bridge in the [proximal; mid; distal] segment]. {If present, stents should be described by size (if known), type (if known), number, and segmental location. Any relation to the adjacent branch vessel ostium should be described. In addition, the stent should be described as patent, occluded, or stenosed. Any in-stent stenosis, fracture, or calcification should also be described} [The ramus intermedius branch [has no stenosis| has mild stenosis | has moderate stenosis | has severe stenosis |is occluded |is nonevaluable] with [no | noncalcified | mixed | calcified] plaque].] Left Circumflex Artery: The left circumflex artery and its obtuse marginal [and left posterior descending artery; and left posterolateral] branches [have no stenosis | have mild stenosis | have moderate stenosis | have severe stenosis | are occluded | are nonevaluable] with [no | noncalcified | mixed | calcified] plaque. {If present, stents should be described by size (if known), type (if known), number, and segmental location. Any relation to the adjacent branch vessel ostium should be described. In addition, the stent should be described as patent, occluded, or stenosed. Any in-stent stenosis, fracture, or calcification should also be described} Right Coronary Artery: The right coronary artery and acute marginal [and right posterior descending artery; and right posterolateral] branches [have no stenosis | have mild stenosis | have moderate stenosis | have severe stenosis | are occluded | are nonevaluable] with [no | noncalcified | mixed | calcified] plaque. {If present, stents should be described by size (if known), type (if known), number, and segmental location. Any relation to the adjacent branch vessel ostium should be described. In addition, the stent should be described as patent, occluded, or stenosed. Any in-stent stenosis, fracture, or calcification should also be described} Cardiac Morphology: The right atrium is [*normal | dilated]. The right ventricle is [*normal | dilated | hypertrophied]. The left atrium is [*normal | dilated]. The left ventricle is [*normal | dilated | hypertrophied]. [There are features of [an interatrial septal defect | an interventricular septal defect | an interatrial and interventricular septal defect | a patent foramen ovale]. The pericardium is [*normal | thickened | calcified] and there is [*no | a small | a moderate | a large] pericardial effusion. The aortic valve [* is tricuspid | is congenitally bicuspid | is functionally bicuspid] with [*normal leaflets | leaflet thickening | leaflet thickening and calcification] [and [*there is no evidence for motion abnormality | regurgitation | stenosis] {reported only if retrospective ECG gating has been used}]. The mitral valve leaflets are [*normal | thickened | thickened and calcified] [and [*there is no evidence for motion abnormality | prolapse of the [anterior; posterior; anterior and posterior] leaflet | a flail [anterior; posterior; anterior and posterior] leaflet | stenosis] {reported only if retrospective ECG gating has been used}]. The heart is [*well separated from | abuts] the sternum. [Cardiac Function {reported only if retrospective ECG gating has been used} The calculated left ventricular ejection fraction is [#] %, the left ventricular end-diastolic volume is [#] mL, and the left ventricular endsystolic volume is [#] mL. There [are no regional wall motion abnormalities | is [hypokinesia | akinesia | dyskinesia] of the [basal; mid ; apical; apex] [anterior wall; anterolateral wall; anteroseptal wall; lateral wall; inferolateral wall; inferoseptal wall; septal wall; inferior wall] of the left ventricle.] [Cardiac Devices and Indwelling Central Venous Lines: {the presence of a pacemaker, central venous line, etc should be discussed here}] Extracardiac findings: The [main; right; left] pulmonary artery is [*normal; enlarged; stenotic]. There [are | are no] filling defects in the [lobar; segmental; subsegmental] pulmonary artery branches consistent with pulmonary arterial embolism. The visualized thoracic aorta is [*normal | enlarged]. {If the aorta is enlarged, dissected, or transected: size, location, and description should be dictated especially for findings of acute aortic syndromes.} The [*lungs; right upper lobe; right middle lobe; right lower lobe; left upper lobe; lingual; left lower lobe] [* are normal | is consolidated | is atelectatic | has a [#] mm nodule | has a calcified granuloma]. The included portion of the upper abdomen [* is normal | demonstrates a [small | moderate | large] sized hiatal hernia | [other]]. Impression: 1. [*Normal coronary CTA without evidence for coronary artery stenosis | Abnormal coronary CTA with []]. {Describe the important coronary CTA findings here. If a calcium score was performed, the total score should also be included in the report impression.} 2. [* Normal | Abnormal] global and regional wall motion and function of the LV. {If abnormal give pertinent findings here.} [3. {Any additional pertinent cardiac findings.}] [4. {Any non-cardiac pertinent findings including lung nodule recommendations. If a lung nodule is described without known malignancy, a statement of the Fleishner Society guidelines for appropriate follow-up should be included in the dictation.}] Result Communication: [Dr. [name] | Dr. [name]’s assistant [name] | [other] was notified [by telephone | in person] of the [*study findings | critical result] at [time] on [date] and they acknowledged receipt of the result. {If this was a critical result, the appropriate critical result guidelines of your institution should be followed.}] 1