Normal CT Abdomen and Pelvis Report Template (With Contrast)
Normal contrast-enhanced CT abdomen/pelvis report template with organ-by-organ FINDINGS and incidental-finding wording (Bosniak, adrenal).
EXAMINATION: CT abdomen and pelvis with intravenous contrast. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Axial helical images from the lung bases through the pubic symphysis following intravenous contrast administration, with coronal and sagittal reformats. FINDINGS: Lung bases: Clear. Liver: Normal size and attenuation. No focal lesion. Gallbladder and biliary tree: Unremarkable. No biliary ductal dilatation. Pancreas: Unremarkable. Spleen: Normal size. Adrenal glands: Unremarkable. Kidneys and ureters: Symmetric enhancement and excretion. No hydronephrosis or renal calculus. Bowel: No obstruction. Normal caliber. The appendix is normal. Mesentery and peritoneum: No free fluid or free air. Lymph nodes: No lymphadenopathy by size criteria. Bladder: Unremarkable. Pelvic organs: Unremarkable for age. Vessels: The abdominal aorta is normal in caliber. Bones: No acute osseous abnormality. IMPRESSION: 1. No acute abnormality in the abdomen or pelvis.
Dictation notes
- An incidental renal cyst gets a Bosniak class on contrast-enhanced CT; an incidental adrenal nodule gets washout or follow-up wording.
- Say the appendix is normal when it is seen — it answers the most common ED question without a call.
Related references
Bosniak 2019 reference · Adrenal washout calculator
Frequently asked questions
What organs should a CT abdomen and pelvis report cover?
An organ-by-organ FINDINGS section covers the lung bases, liver, gallbladder and biliary tree, pancreas, spleen, adrenal glands, kidneys and ureters, bowel including the appendix, mesentery and peritoneum, lymph nodes, bladder, pelvic organs, vessels including aortic caliber, and bones. Addressing each organ with an explicit statement, even when normal, documents the review and gives later comparisons an anchor. The normal impression is 'No acute abnormality in the abdomen or pelvis.'
How should an incidental renal cyst on CT be reported?
On contrast-enhanced CT, an incidental cystic renal mass should be assigned a Bosniak class, stating that the 2019 version is being used. Bosniak I and II lesions are benign and need no follow-up; IIF lesions get surveillance imaging; III and IV lesions go to urology. A simple statement like 'renal cyst' without a class leaves management undefined. Incidental adrenal nodules analogously receive washout characterization or follow-up wording.
Why should a CT report state that the appendix is normal?
Explicitly stating 'the appendix is normal' when it is visualized answers the most common emergency department question without a phone call and documents that the structure was specifically reviewed. Silence about the appendix is ambiguous — it may mean normal, not seen, or not assessed — and that ambiguity drives callbacks and repeat imaging. If the appendix is not identified, saying so is equally useful.
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