Home › Report templates › Normal CT Chest, Abdomen and Pelvis Report Template (Trauma)
Normal CT Chest, Abdomen and Pelvis Report Template (Trauma)
Normal trauma CT chest/abdomen/pelvis report template: arterial and portal venous phase wording, organ-by-organ solid viscera, bowel, mesentery, free fluid and the full osseous survey, with AAST grading and delayed-phase notes.
EXAMINATION: CT chest, abdomen and pelvis with intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Trauma”] COMPARISON: None available. TECHNIQUE: Axial helical images from the thoracic inlet through the pubic symphysis after the intravenous administration of [x] mL of [contrast agent], acquired in the [arterial and portal venous] phase(s), with coronal and sagittal reformats. Dose reduction techniques were used. FINDINGS: CHEST Lungs and airways: Clear. No pulmonary contusion, laceration or pneumothorax. The central airways are patent. Pleura: No pleural effusion or hemothorax. Heart and great vessels: Normal heart size. No pericardial effusion. The thoracic aorta is normal in caliber and contour, without intimal flap, pseudoaneurysm or periaortic hematoma. The great vessels are intact. Mediastinum: No mediastinal hematoma or pneumomediastinum. Chest wall: No rib, sternal or scapular fracture. ABDOMEN AND PELVIS Liver: Normal attenuation and enhancement. No laceration, contusion or subcapsular hematoma. Spleen: Normal size and enhancement. No laceration or perisplenic hematoma. Pancreas: Normal, without peripancreatic fluid or ductal disruption. Adrenal glands: Unremarkable. No adrenal hematoma. Kidneys: Symmetric enhancement. No laceration, perinephric hematoma or urinoma. No hydronephrosis. Bladder: Decompressed by Foley catheter / normally distended. No intraperitoneal or extraperitoneal bladder rupture. Bowel and mesentery: Normal caliber and wall thickness. No bowel wall thickening, mesenteric hematoma, mesenteric stranding or free air. Vessels: The abdominal aorta and major branches are intact. No active extravasation or pseudoaneurysm. Peritoneum: No free fluid or hemoperitoneum. Pelvis: Unremarkable reproductive organs for age. No pelvic hematoma. OSSEOUS STRUCTURES Spine: Normal alignment of the visualized thoracic and lumbar spine. No vertebral body, posterior element or transverse process fracture. Pelvis: The pelvic ring is intact. No acetabular, sacral or pubic fracture. The sacroiliac joints and pubic symphysis are normally aligned. Other: No proximal femoral fracture. IMPRESSION: 1. No acute traumatic injury of the chest, abdomen or pelvis.
Dictation notes
- Grade every solid-organ injury by the AAST scale (liver, spleen, kidney, pancreas) with the laceration depth, hematoma size and presence of active extravasation or contained vascular injury — the surgeon triages to the grade, not to “laceration”.
- Isolated free fluid without a solid-organ injury in a male patient is bowel or mesenteric injury until proven otherwise — say that in the impression and recommend short-interval repeat CT or clinical observation, not “likely physiologic”.
- A renal or bladder injury needs a delayed excretory phase to separate hematoma from urine leak — when the arterial phase shows a deep renal laceration or pelvic fracture with free fluid, obtain delays before the patient leaves the scanner.
- Report contrast extravasation as active (grows between phases), contained (pseudoaneurysm, washes out) or none; the distinction sends the patient to angiography versus observation.
- The “trauma vertebral survey” is dictated from the sagittal reformats — transverse process fractures are a marker of adjacent visceral and vascular injury, so name each level.
Related references
How to dictate CT abdomen/pelvis
Never paste a template again
MyRadAgent turns a scratch dictation into this report — structured, guideline-checked, in your own section headers and phrasing. It learns your style from every correction. Free trial: 100 reports over 14 days, no card, no IT ticket.
Draft a report with it → or watch the live demo first — no signup →This is a reference implementation of a published guideline, for use by qualified clinicians. It does not account for patient-specific factors and is not a substitute for clinical judgment or a formal radiology consultation. Templates are generic scaffolds for licensed radiologists; verify wording against your own practice standards. See our full disclaimer.