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Missing Image & CT Evaluation
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Sample, Sammy G
ST0001
PET Evaluation Form
1234567890
Study date
MM/DD/YYYY
Radiologist
Radiologist NPI
PET scan performed at outside institution
PET scan performed at outside institution
No
Yes
Date of baseline CT
Date of baseline CT
MM/DD/YYYY
Date of most recent comparative study
Date of most recent comparative study
MM/DD/YYYY
Are there any nodules noted in the CT scan?
Are there any nodules noted in the CT scan?
No
Yes
Are non-calcified nodules noted, all less than 6 mm?
Are non-calcified nodules noted, all less than 6 mm?
No
Yes
List any nodule(s) of concern* in the table below. If baseline >= 6 mm or if repeat, >= 3 mm
Enter the Nodule Uptake values and update the Nodule Status to reflect the results of the PET study, and update the neccesary actions for each nodule, as indicated. Enter any details given in the PET report in the PET Details field.
Update the Follow-up section.
Nodule ID
Nodule 1
Additional Nodules
Nodule 2
Nodule 3
Nodule 4
Nodule 5
Is it new?
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
-
Newly seen
Prev seen, no change
Prev seen, slight decr
Prev seen, marked decr
Prev seen, slight incr
Prev seen, marked incr
Prev seen, obscured
Prev seen, resolved
Prev seen, not a nodule
Prev seen, resected
Retrospect, no chg
Retrospect, decrease
Retrospect, slight incr
Retrospect, marked incr
Not in outside report
Not included in scan
Most likely location
-
Endobr
LUL
LLL
RUL
RML
RLL
-
Endobr
LUL
LLL
RUL
RML
RLL
Maximum nodule uptake (SUV)
Nodule status
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
-
Unknown
Benign (Ca++)
Prob benign, prob Ca++
Resolved
Resolving
No change - 2 yrs
PET - positive
PET - negative
PET - indeterminate
Biopsy - unknown
Biopsy - benign
Biopsy - malignant
Biopsy - atyp bronch prolif
Biopsy - metastatic
Resected - malignant
Resected - benign
Pathologic diagnosis
-For Pathology Use Only-
AAH
Atyp bronch prolif
BAC
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
-For Pathology Use Only-
AAH
Atyp bronch prolif
BAC
Unspec. non-small cell
Adenocarcinoma
Adenosquamous
Large cell
Squamous cell
Small cell
Carcinoid - typical
Carcinoid - atypical
Not malignant
Benign specific
Other (specify)
Indicate the index nodule driving follow up:
Indicate the index nodule driving follow up:
-
1
2
3
4
5
LungRADS category
LungRADS category
-
0
1
2
3
4A
4B
4X
LungRADS modifier
LungRADS modifier
S
C
PET details - lung and nodules
PET details - lymph nodes
Other clinically significant ancillary finding?
Other clinically significant ancillary finding?
No
Yes
Organ/Location
-
Breast
Abdomen
Head
Neck
Describe
Organ/Location
-
Breast
Abdomen
Head
Neck
Describe
Comments
Any other findings
Follow Up
Follow-up
-
Annual repeat CT
Follow-up CT
Abx + follow-up CT
PET
CT w contrast
CT-guided biopsy
Bronchoscopy
VAT
Resection
When
MM/DD/YYYY
Now
1 month
3 months
6 months
1 year
Other
Impression
Nodules
No evidence of abnormal uptake. Follow-up as recommended above.
Uptake as described above. Follow-up as recommended above.
Nodule(s) unchanged, as described above. Follow-up as recommended above.
Other findings
No other abnormalities.
Other abnormalities and suggested follow-up as described above.
Diffuse abnormalities.
Impression remarks
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