Report template

Report template — CT of joints

CT report template for joints — clinical body in pt-BR with [...] placeholders for exam-specific findings.

When to use

Head and neck/face CT evaluates sinus disease, facial fractures, orbital disease, sella, ears/mastoid and TMJ. For neck soft tissues and ENT neoplasm workup, it is often the initial exam; MRI complements in complex lesions and parotid/marrow assessment.

What to evaluate

  • Paranasal sinuses: pneumatization, mucosal thickening, content, ostiomeatal complex.
  • Facial bones: fractures (LeFort I/II/III, orbital wall, zygomaticomaxillary complex).
  • Orbits: globe, extraocular muscles, intraorbital fat, optic nerve.
  • TMJ: articular surfaces, spaces, degenerative signs.
  • Middle and inner ear: ossicular chain, cochlea, semicircular canals.

Interactive template

Fill the blanks0/4

ARTROTOMOGRAFIA COMPUTADORIZADA DA Técnica: Aquisição volumétrica. Administrada previamente solução de contraste iodado intra-articular. Análise: - : de morfologia preservada e sem sinais de lesão. - Superfícies articulares: ausência de lesões osteocondrais. - Demais estruturas ósseas: morfologia conservada. Ausência de fraturas ou de lesões ósseas focais de aspecto agressivo. - Estruturas musculotendíneos: ausência de lesões musculares ou tendíneas. - Planos superficiais: sem alterações significativas. Comparação: Em relação ao exame de não se observam alterações significativas. Conclusão: Exame dentro dos limites da normalidade.
Template in Brazilian Portuguese (clinical reporting language). Adapt to your service protocol. Not medical advice — the physician reviews, edits and signs.

How to use

  • Replace each [...] with the exam's measurement or descriptor.
  • Adapt the conclusion to your service protocol before signing.
  • Use the template as a starting point — not a replacement for physician review.
  • In Laudos.AI, dictate findings in natural speech and the AI structures text in this format for review.

Frequently asked

Rhinosinusitis — when to order CT?
Recurrent sinusitis, suspected complication (orbital cellulitis, abscess), pre-op FESS. Not initial for uncomplicated acute sinusitis.
LeFort fracture — how to distinguish?
LeFort I (low transverse, separates palate), II (pyramidal, crosses orbit), III (complete craniofacial disjunction).

References

  • ACR Appropriateness Criteria — Sinonasal Disease.

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