{"id":"69a08eb50015b6bb44a379e8","name":"CT Head Without Contrast - voice obtimized (Copy)","slug":"ct-head-without-contrast-voice-obtimized","description":"Structured template for non-contrast CT imaging of the brain, optimized for voice-to-text reporting with enhanced vocabulary recognition for normal and pathological findings.","category":{"modality":"CT","system":"CNS"},"tags":["head","brain","non-contrast","stroke protocol","trauma","acute","hemorrhage screening"],"sections":{"title":{"defaultText":"CT Head Without Contrast","aiInstructions":"Use the provided title. If the report mentions specific protocol (e.g., stroke protocol, trauma protocol), incorporate into title only if explicitly stated."},"clinicalHistory":{"defaultText":"[Patient-specific — populated at report time]","aiInstructions":"Ask the user for: patient age, sex, presenting complaint, relevant clinical history, and reason for the exam. This section contextualizes the entire report. Always include it."},"comparison":{"defaultText":"No prior studies available for comparison.","aiInstructions":"If prior studies are mentioned in the input, document them specifically. Otherwise, use default text."},"technique":{"defaultText":"Axial non-contrast CT images of the head were obtained.","aiInstructions":"Describe the imaging technique used. Include slice thickness, reconstruction parameters, and coverage if mentioned in source material. For non-contrast head CT, standard phrasing is acceptable."},"findings":{"defaultText":"The brain parenchyma demonstrates normal gray-white matter differentiation. The ventricles and sulci are normal in size and configuration. There is no evidence of intracranial hemorrhage, mass effect, or midline shift.","aiInstructions":"Synthesize findings from individual anatomical fields into a cohesive overview. Lead with major findings (hemorrhage status, mass presence). Follow with normal structures if no abnormality is present.","fields":[{"name":"Brain Parenchyma","defaultText":"Normal gray-white matter differentiation is preserved. No focal areas of abnormal density.","aiInstructions":"Document the overall appearance of gray and white matter. Note any hypodense or hyperdense regions, edema, or signal abnormality if present."},{"name":"Ventricles and Cisterns","defaultText":"The lateral, third, and fourth ventricles are normal in size and configuration. The basal cisterns are patent.","aiInstructions":"Assess ventricular size and symmetry. Document any enlargement, compression, or obliteration of cisterns. Note hydrocephalus if present."},{"name":"Sulci and Gyri","defaultText":"Cortical sulci and gyri are normal in appearance without abnormal prominence.","aiInstructions":"Describe sulcal pattern. Note any focal atrophy, widening, or obliteration if present."},{"name":"Intracranial Hemorrhage","defaultText":"No evidence of acute intracranial hemorrhage.","aiInstructions":"Explicitly assess for subarachnoid, epidural, subdural, and intraparenchymal hemorrhage. If present, specify location, volume, and character."},{"name":"Mass and Mass Effect","defaultText":"No intracranial mass or mass effect. No midline shift.","aiInstructions":"Document presence or absence of mass lesions. Assess for mass effect including compression of ventricles and midline shift. Specify location and size if abnormality identified."},{"name":"Cerebellum and Brainstem","defaultText":"The cerebellum and brainstem are normal in appearance.","aiInstructions":"Assess cerebellar hemispheres, vermis, and brainstem for hemorrhage, infarction, or mass. Note any compression of fourth ventricle."},{"name":"Skull and Calvarium","defaultText":"The skull and calvarium are intact. No fractures identified.","aiInstructions":"Evaluate bone windows for fractures, lytic or sclerotic lesions. Document location and extent of any fractures if present."},{"name":"Paranasal Sinuses","defaultText":"The paranasal sinuses are clear and well-aerated.","aiInstructions":"Assess frontal, maxillary, and sphenoid sinuses for opacification, air-fluid levels, or mucosal thickening if visible."},{"name":"Mastoid Air Cells","defaultText":"The mastoid air cells are well-aerated.","aiInstructions":"Document aeration status. Note any opacification or fluid levels if present."}]},"impression":{"defaultText":"No acute intracranial abnormality. No evidence of intracranial hemorrhage or mass.","aiInstructions":"Synthesize key findings into a concise impression. Prioritize acute findings (hemorrhage, mass, infarction). State presence or absence of clinically significant abnormalities. If normal, confirm absence of acute pathology."}},"aiUsageInstructions":{"summary":"Use this template to generate a complete CT Head Without Contrast - voice obtimized (Copy) radiology report.","steps":["1. Collect patient clinical history from the user (age, sex, clinical indication).","2. Confirm whether prior studies are available for comparison.","3. For the Technique section, use defaultText or adapt based on actual acquisition parameters.","4. For each field in sections.findings.fields: ask the user for the finding or infer from clinical context. Use defaultText if the structure is normal.","5. Generate the Impression by summarizing the most significant findings from step 4.","6. Use the aiInstructions for each section to guide the depth and format of the content.","7. Maintain formal radiology report language throughout. Passive voice preferred.","8. If any finding is abnormal, quantify it with measurements and describe its imaging characteristics."],"language":"Formal radiology report language. Passive voice preferred. Avoid first-person pronouns.","format":"Numbered impression list. Prose findings paragraphs or structured field-by-field format both acceptable.","units":"Report measurements in centimeters (cm) for masses, millimeters (mm) for small structures."},"meta":{"canonicalUrl":"https://radiluxreports.com/templates/ct-head-without-contrast-voice-obtimized","claudeApiUrl":"https://radiluxreports.com/templates/api/claude/ct-head-without-contrast-voice-obtimized","useInDashboardUrl":"https://radiluxreports.com/?templateId=69a08eb50015b6bb44a379e8","apiUrl":"https://radiluxreports.com/templates/api/ct-head-without-contrast-voice-obtimized","updatedAt":"2026-02-28T23:42:08.744Z","license":"Free for clinical and educational use. Attribution appreciated."}}