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.

⁶⁷Ga-citrate SCAN OF THE TOTAL BODY PERFORMED ON [date]

Clinical Statement: A 30 year old man with a history of right thigh sarcoma and multiple surgical procedures, with persistent drainage.

Procedure: Following intravenous administration of 10 mCi?⁶⁷Ga-Citrate, whole body images, supplemented by SPECT [SPECT/CT] images of the right lower extremitiy, were recorded at 24 hours.

Comparison: No previous?⁶⁷Ga-Citrate scan available for comparison.

Correlation: AP and lateral bone radiographs of the right thigh, which demonstrated a fixation pin in the mid-femur.

Findings: Focal?⁶⁷Ga-Citrate localization is seen in the right medial thigh, adjacent to the mid-femur, in the region of a fixation pin.

There is a physiologic distribution of radioactivity in the nasopharynx, chest, liver, spleen, and bowel.

Impression: Probable infection in the right mid thigh and, associated with the fixation pin.