Report template

Report template — CT of thigh

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

When to use

MSK CT is the standard for complex fractures (acetabulum, calcaneus, scaphoid), orthopedic pre-surgical planning, torsional profile of limbs and focal bone lesions. For soft tissue, ligaments and bone marrow, MRI is superior.

What to evaluate

  • Fractures: line, displacement, fragments, articular involvement.
  • Focal bone lesions: matrix, margin pattern, periosteal reaction.
  • Articular surfaces and congruence.
  • Intra-articular loose bodies.
  • Adjacent soft tissues (limited vs MRI).

Interactive template

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Técnica: Aquisição volumétrica sem contraste. Análise: - Fraturas: ausentes. - Lesões ósseas agressivas: ausentes. - Estruturas ósseas: preservadas. - Superfícies articulares: regulares. - Derrame articular: ausente. - Planos musculoadiposos: preservados, sem formações com efeito expansivo. 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

When CT instead of XR for fracture?
Strong clinical suspicion with inconclusive radiograph (scaphoid, occult scaphoid, ribs, coronoid), complex fractures for surgical planning, and assessment of union.
Lytic bone lesion — when MRI complements?
Whenever primary tumor or metastasis is suspected — MRI better evaluates the marrow component and soft-tissue extension.

References

  • ACR Appropriateness Criteria — Acute Trauma to the Foot/Ankle/Wrist.

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