Normal Chest CT Report Template (With Contrast)
Normal contrast-enhanced chest CT report template: lungs, airways, mediastinum, pleura and bones, with incidental-nodule wording per Fleischner.
EXAMINATION: CT chest with intravenous contrast. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Axial helical images through the chest following intravenous contrast administration, with coronal and sagittal reformats. FINDINGS: Lungs: Clear. No focal consolidation, suspicious nodule or mass. Airways: Patent central airways. Pleura: No pleural effusion or pneumothorax. Heart and vessels: Normal heart size. No pericardial effusion. The thoracic aorta and central pulmonary arteries are normal in caliber. Mediastinum and hila: No lymphadenopathy by size criteria. Chest wall and bones: No acute osseous abnormality. No suspicious lesion. Upper abdomen: Grossly unremarkable on included images. IMPRESSION: 1. No acute cardiopulmonary abnormality.
Dictation notes
- Apply Fleischner follow-up wording to every incidental nodule in a qualifying patient — category plus interval, in the impression.
- Comment on the included upper abdomen; incidental adrenal and hepatic findings are a common miss.
Related references
Fleischner calculator · Nodule doubling time
Frequently asked questions
What sections belong in a normal contrast-enhanced chest CT report?
A structured chest CT report covers the lungs (no consolidation, suspicious nodule or mass), central airways, pleura (no effusion or pneumothorax), heart and vessels including aortic and pulmonary artery caliber, mediastinum and hila (no lymphadenopathy by size criteria), chest wall and bones, and the imaged upper abdomen. The normal impression reads 'No acute cardiopulmonary abnormality.'
How should an incidental lung nodule on chest CT be reported?
Every incidental nodule in a qualifying patient should carry Fleischner Society 2017 follow-up wording — the nodule type and size, the category, and the recommended interval — placed in the impression. Fleischner applies to incidental nodules in patients 35 and older without known malignancy or immunocompromise; nodules found on lung cancer screening CT are categorized with Lung-RADS instead. Size is the average of long and short axis.
Why should a chest CT report comment on the upper abdomen?
The lung bases series routinely includes the upper abdomen, and incidental adrenal nodules, hepatic lesions and renal findings there are a recognized source of missed pathology. A brief statement — even 'grossly unremarkable on included images' — documents that the region was reviewed. When an incidental adrenal or hepatic lesion is present, it should be characterized or given explicit follow-up wording per the relevant incidental-findings guidance.
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