Writing a Radiology Report Patient Name/DOB/Age/Gender/Date of Study/Date of Report/Referring Dr. Examination Type: (Conventional Radiograph/MRI/CT) + Body Part (Upright Thoracic Spine) View: AP/Lateral/Oblique (cervical/thoracic/lumbar) Findings: Paragraph 1: A: Alignment: Coronal plane curves: List/Lean/Shift; Pelvic unleveling; Scoliosis. Scoliosis should be measured. Convexity points to the side you call it. And Mention rotation. Sagittal plane curves: Lordosis/Kyphosis= increased, decreased, focal changes. Mild/Moderate/Severe Listhesis: 4 items 1. Level 2. Direction: Antero/Retro/Latero 3. Degree: Grade 1, 6mm 4. Due to: Spondylolytic, degeneragive Measurements: pertinent to the area being evaluated o Every cervical should have the ADI measured (>3mm Adult/>5mm Child) o For non-standard measurements include if + (Ex. McGregor’s Line) Anomalies: Extra/Missing parts; Check at transitional areas! o Ex. Lumbosacral Transitional Segments o Castellvi 1: Spatulation without articulation o Castellvi 2: Spatulation with articulation 2A: Unilateral accessory joint 2B: Bilateral accessory joint o Castellvi 3: Complete Fusion 3A: Unilateral 3B:Bilateral o Castellvi 4: Combined fusion and accessory joint Missing Psoas shadow: Ascites Paragraph 2: Bone/Cartilage: Overall bone density: Normal/Increased/Decreased; Grade- Mild/Moderate/Severe Generalized/Localized? “Cortical margins intact, trabecular patterns are normal” Check all cortical margins, patterns and PEDICLES! Disruptions: Alignment, apposition, rotation Sclerosis, lysis, missing structures, shapes/sizes of vertebra (anterior wedging, trapezoidal shape, endplate abnormalities) Talk about all major joint spaces in the view! o In Cervical Spine: Discs, facets, uncinates o Lumbar: Discs, facets, SI joints, Hips Always grade changes: Mild/Moderate/Severe Joint Space Loss Spondylophyte formation (especially if posterior) Spondylophyte vs. syndesmophyte Facet Joints: Sclerosis, Hypertrophy, Osteophyte formation Uncinates: sclerosis, hypertrophy, osteophytes; might need oblique view Costovertebral/Costotransverse: Rib DJD SI Joints: Cortical margins, irregularity, sacroilitis, sclerosis, might need AP angulated spot view Extra Axial- Grade changes Mild/Moderate/Severe o Evaluate: joint spaces, subchondrial sclerosing, osteophytes, erosions, loose bodies Measurements: o AC joint space for impingment o Anterior Humeral Line: supracondylar Fx o Scapholunate Space, VISI/DISI in wrist o 3 Joint spaces of the hip o Boehler’s Angle for calcaneal Fx Paragraph 3: Soft Tissues: Cervical: Adenoidal hypertrophy, prevertebral soft tissues (2’s 6’s) Midline trachea, Lung Apices, Calcifications of carotids “No distension of the prevertebral soft tissues is noted. The trachea is in midline. The lung apices are clear of gross pathology.” Thoracic: Trachea midline, cardiomedialstinal silhouette, lung fields, hili, clear spaces, paravertebral soft tissue stripe hemidiaphragms, upper abdomen: magenblasse, liver, spleen “No distension of the paravertebral soft tissue stripe is noted. The visualized lung fields are clear of gross consolidation, mass, or interstitial disease. The trachea is in midline. The cardiomediastinal silhouette is unremarkable.” Lumbar: Hemidiaphragms, lung bases, psoas shadow (ascites) solid organ pattern (presence, laterality- situs inversus) Organomegally, ectopia, Bowel (contents/contour) Presacral space (lateral view); Bladder, Vascular (abdominal aorta) “The psoas shadows are symmetric. The bowel is normal in contents and contour. No abdominal masses, pelvic masses, or organomegaly is seen.” Look For: Masses, Calcifications, Displacement if fascial planes, Organ Shadows Extremities: Capsular fat pads: Scaphoid, posterior elbow, hip; Joint effusion (supra patellar pouch, FBI sign) Tendon/ligament/muscle/ misc calcifications. HADD-myositis ossificans/HPT or diabetic vascular calcinosis Impressions: Numbered List that goes with every finding. Worst first!! Give a diagnosis or differential list; do not exceed 3 Example: Expansile, geographic, lytic lesion in right ilium. o Differential possibilities include: ABC, GCT, and eosinophilic granuloma. See recommendation #1. Mild loss of intervertebral disc space with spondylophyte formation is seen at L4-S1. o Mild degenerative disc disease, L4-S1 Multipule foci of dense sclerosis are noted thoughout the lumbar spine, sacrum, and ilium. These foci are not expansile, demonstrate a wide zone of transition. o Findings suggestive of blastic metastasis. See recommendation #1. Recommendations: ONLY if: additional imaging, Lab tests, or Referrals are needed. Tell specific views needed, tests to be run or specific Dr. that needs to be seen. Example: o An MRI of the lumbar spine and a bone scan is recommended in order to further evaluate the possibility of blastic metastasis. Laboratory evaluation to include ESR, PSA, and chemistry panel. o An MRI of the distal radius is recommended for more thorough evaluation of this lesion. Additional Issues: If the films suck: explain what’s wrong with them @ beginning of “Findings” section If you don’t know: o Describe is, differential it, then have films read by a radiologist. If there are previous radiographs: First sentence of “Findings” comment on comparison. o “Comparison is made with [insert exam and views] performed on [insert date of exam] at [facility].