Infection/Inflammation (Tagged WBC) Scan Report

Patient: [name, MRN, DOB, sex]

Exam: Infection/Inflammation (Tagged WBC) Scan [SPECT/CT / with Bone Marrow Imaging] (Include qualifier(s) only if performed.)

Date: [exam date]

Ordering Provider: [name/service]

Interpreting Physician: [name]

Indication

[Primary clinical question and brief relevant history] (1–3 sentences. Include the clinical question, symptom duration, pertinent risk factors, presence/type of hardware or grafts, and pertinent labs if available. If minimal history: "Additional clinical history not provided.")

Comparison

[Prior relevant imaging with modality and date] (Prioritize prior WBC scans, bone marrow/bone scans, FDG PET, and CT/MRI. If none: "No prior relevant imaging available for comparison.")

Technique

Radiopharmaceutical: [Tc-99m HMPAO-labeled / In-111 oxine-labeled] autologous leukocytes; [administered activity]; [route]; [injection date and time] (Required fields—retain placeholders if not available.)

Acquisition: [planar / whole-body / SPECT/CT] of [anatomic coverage]

Imaging Timepoints: [early / delayed / late with approximate post-injection times] (Required—retain placeholders if not available.)

[SPECT/CT details: low-dose vs diagnostic-quality CT; bone marrow tracer and timing; significant infiltration, contamination, or artifacts] (Include only applicable elements.)

Findings

[Image quality and physiologic distribution statement] (Include if abnormal or if technical limitations present.)

[Primary site of concern: anatomic location with laterality and relation to hardware/grafts; pattern; intensity relative to reference structures; temporal behavior across timepoints] (For SPECT/CT: integrate bone vs soft tissue localization and relevant CT features. For marrow imaging: state concordant vs discordant WBC/marrow uptake.)

[Additional sites of abnormal tagged-WBC accumulation using same descriptors] (Include only if applicable.)

[Explicit negative statement addressing the indication] (Include for negative studies.)

[Clinically actionable incidental findings] (Include only if present.)

Impression

1. [Conclusion addressing the primary clinical question: positive / negative / indeterminate for infection; location and extent; bone vs soft tissue involvement] (Base on documented criteria: temporal increase, marrow mismatch, anatomic localization. For spine evaluations, acknowledge WBC scintigraphy limitations when relevant.)
2. [Secondary conclusions or additional sites] (Include only if applicable.)
3. [Interval change compared with prior imaging] (Include if comparison available.)
4. [Recommendation for aspiration/culture, cross-sectional imaging, or follow-up scan] (Include only if clinically warranted. Do not imply microbiologic etiology.)

Communication

[Recipient name/role; method; date; time] (Include this section only if urgent or unexpected findings were communicated; otherwise omit entire section.)