Ventilation/Perfusion (V/Q) Lung Scan Report

Procedure: Ventilation/Perfusion (V/Q) Lung Scan

Acquisition Type: [Planar / V/Q SPECT / V/Q SPECT/CT] (If V/Q SPECT/CT, specify CT purpose: [low-dose for attenuation correction and anatomic correlation / diagnostic-quality CT].)

Date: [Study date]

Ordering Provider: [Name, credentials]

Interpreter: [Name, credentials]

Report Status: [Preliminary / Final / Addendum]

Indication

[Primary clinical question] (State succinctly in one sentence, e.g., evaluate for pulmonary embolism.)

[Relevant clinical context: symptoms and timing, D-dimer result, pretest probability or clinical decision tool score, pertinent thromboembolic history, reason CTA not performed] (Include only elements explicitly provided by referrer. Do not infer clinical probability or risk factors. If clinical history is minimal, state: "Clinical history as provided: [brief statement].")

Comparison

[Relevant prior studies with dates: prior V/Q scans, chest radiograph, CT chest, CTPA, lower extremity venous ultrasound] (If chest radiograph or CT was not available for correlation, explicitly state this.)

Technique

• Protocol: [Full V/Q / Perfusion-only] (If perfusion-only, state reason if known.)
• Imaging order: [Ventilation first / Perfusion first]
• Perfusion injection position: [Supine / Prone / Upright] (Include if captured.)
• Ventilation agent: [Tc-99m DTPA aerosol / Xe-133 gas / Technegas], [administered activity]
• Perfusion agent: Tc-99m MAA, [administered activity] (Include particle number if modified for clinical reasons.)
• Acquisition: [Planar projections / SPECT acquisition]
• Study quality: [Quality assessment and any technical limitations] (Note limitations such as motion artifact, poor ventilation cooperation, central airway deposition, low counts, or extensive parenchymal disease if present.)

(If perfusion-only, include explicit statement regarding interpretive limitations.)

Findings

Correlative imaging: [Pertinent findings from chest radiograph or CT with study date] (If no correlative imaging available, explicitly state this.)

Ventilation: [Distribution: homogeneous / heterogeneous]; [focal ventilation defects with locations if present]

Perfusion: [Distribution: homogeneous / heterogeneous]; [perfusion defects with locations if present]

V/Q analysis:

• Mismatched defects: [Location, size class (segmental / subsegmental), number, distribution, vascular morphology, estimated extent] (Include if present.)
• Matched defects: [Location and extent] (Include if present.)
• Reverse mismatch: [Location and extent] (Include if present.)

(If ventilation was not performed, state this limitation and characterize perfusion defects with reference to correlative imaging.)

Impression

1. Primary interpretation: [Interpretation addressing clinical question] (State interpretive framework used. For PE evaluation, provide category: [Normal / Very low probability / Low probability / Intermediate / High probability] or [PE present / PE absent / Nondiagnostic]. Include basis for conclusion. If indeterminate or nondiagnostic, include imaging recommendation.)
2. [Secondary findings or alternate diagnoses] (Include if present.)
3. [Critical result communication: time, method, recipient] (Include if applicable per institutional policy.)