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CT ABDOMEN [AND PELVIS] WITHOUT AND WITH CONTRAST – RENAL MASS/LESION
PROTOCOL
{Used for workup of known or suspected cystic or solid renal lesions, not
intended for hematuria screening.}
CLINICAL INDICATION: [Evaluate renal mass(es)*].
COMPARISON: [<date> | None*].
TECHNIQUE: {Institution specific, with verbiage regarding post-processing
per
institution protocol as necessary for billing and coding purposes.}
Unenhanced and multi-phasic contrast enhanced imaging of the abdomen [and
pelvis]. Scan phases:[Non-contrast| corticomedullary| nephrographic|
excretory].
{Post-processing description}
IV contrast: [# ml] [<Contrast agent and concentration>]
Oral contrast: [None]
CT radiation dose: {Dose
CTDLP: xxx
mGy*cm, for example.}
FINDINGS:
Right kidney: [Unremarkable, no concerning cystic or solid mass
lesions.*]
{Module for description and characterization of a renal mass.
default statement with the following description.}
Replace
Lesion: [none |solitary*] [ ]{add number for 2 or more}
- Location: Lesion centered in:[]
{Anterior/posterior/posteromedial/anteromedial/lateral}
{upper pole/mid/lower pole}
- Image location: series [#] image [#]
- Size: [# x # cm]
- Composition: [ simple cyst *| solid lesion| cystic lesion| hemorrhagic
cyst
][ ]
- Calcification present: [none* | benign pattern | suspicious for
malignancy |
indeterminate character] [ ]
- Cystic lesion features: [Not applicable | few fine septa | thick septa
and/or nodules | enhancing masses/nodules suspicious for malignancy | low
suspicion indeterminate features that should be followed][ ]
- Solid lesion enhancement: [Not applicable | homogeneous enhancement |
heterogeneous enhancement] Hounsfield unit change from pre-contrast: [ ]
- Renal vein invasion: [present | not present]. Extent: [ ]
- Extension through renal capsule [indeterminate | present | not
present].
Extent: [ ]
- Extension beyond Gerota’s fascia [present | not present]. Extent: [ ]
- Additional renal findings: [none* ]
- Perinephric adenopathy: [None*| Present|
{If nodes present, insert following node module}
Node [#n], Image location: series [#], image [#]: Size: [# x # cm];
Shape:
[round; oblong]. {comment} [free text]
Left kidney: [Unremarkable, no concerning cystic or solid mass lesions.*]
Remainder of examination:
Lower thorax: [Unremarkable*]
Liver: [Unremarkable* ]
Spleen: [Unremarkable*]
Pancreas: [Unremarkable*]
Adrenal glands:
[Unremarkable*]
Retroperitoneum: [No adenopathy*]
Peritoneum: [No masses or ascites*]
Pelvis: [Normal* | Not imaged]
Musculoskeletal: [Unremarkable*]
IMPRESSION:
1.
[ ]