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- Abstracting the Medical Records
- Composition of a Medical Record
- Abstracting Diagnostic Procedures
- Clinical Examinations
- Manipulative Procedures
- Operative Procedures
- Pathological Examinations
- Additional Information
Radioisotope Scan Report Example 1
View the suggested abstraction.
The Division of Nuclear Medicine Radioisotope Scan Report
- Name: Brenda Brainard
- Hospital No.: 000012
- Age: 40
- Sex: Female
- Race: White
- Service: Neurology
Procedure Performed: Brain Scan
- Date of Scan: 12/2/91
- Isotope: Tc-99 cm
- Dose: 10 mCi
- Time Isotope Administered: 12:40
- Isotope Energy: 140
- Half-Life: 6 hrs.
- Time Scan Started: 1:20
- Instrument: I
- Area Scanned: Head
- CRD: 30
- Speed: 120
- Range: 30K
- Time Constant: 0.01
- Dot Factor: 16
- Density: 25
- Line Spacing: 0.4
- Light H.V. 900
- Probe H.V. 521
- Window: 120-170
- Maximum CPM: 22,000
- Minimum CP: ____
- Thyroid Uptake: _____
Interpretation:
Brain scans done in multiple projections on the camera with and without perchlorate and by the rectilinear technique reveal a definite peripheral increase in tracer localization on the right seen in the posterior view. This is compatible with subdural disease.
Impression:
Abnormal brain scan - peripheral right abnormality compatible with subdural disease.
Newell Clear, MD
Nuclear Medicine Service



