Radiology Reporting
Structure of a Radiology Report
History
A complete history:
Increases our specificity and sensitivity
Allows for more tailored and relevant reports
Keys points for pain:
Location, location, location!
Acute vs chronic
Suspected differential (e.g. suspect appendicitis or diverticulitis or obstructing renal stone)
Keys points for oncology:
Pathology (even subtypes of cancer look different!)
Treatment history (surgery, radiation, chemotherapy, etc.)
Comparison
Often our most important tool
Check for outside imaging!
Certain pathologies (e.g. fractures) can appear age indeterminate
May have to hedge and recommend "clinical correlation" if only one time point
Growth Rate guides etiology
Lung consolidation developing in 1 month = likely pneumonia
Lung consolidation developing over years = likely malignancy
Long term stability often implies benignity
Technique
Includes information such as use of contrast, body parts scanned, and what timing
The way the study is performed (protocol) should be tailored to the clinical question
A useful resource is the ACR appropriateness criteria for protocoling
Findings
Typically the largest section, comprising the description of all relevant findings
Up to radiologists' discretion what to include as clinically relevant. Some findings may be deemed "unremarkable" such as:
Ovarian cystic lesions compatible with physiologic follicles
Scattered minimal osseous degenerative changes
Tips for your report
On noncontrast CT, findings are described as hypodense, isodense, or hyperdense
On postcontrast CT, findings are described as hypoenhancing, isoenhancing, or hyperenhancing, relative to background organ/parenchyma
Impression
First impression point should answer the clinical question! For example:
"No acute pathology of the abdomen or pelvis" (for acute abdomen/pain)
"No suspicious mass of the abdomen or pelvis" (for weight loss/malignancy evaluation)
Additional impression points should summarize any other clinically relevant findings
Should not be just a repeated list of findings!
e.g. "colonic diverticulosis without diverticulitis" can be excluded unless a pertinent negative
e.g. "stable lymph node" does not give the reader information as to if this is a stable reactive node, stable metastasis, or is indeterminate
Example Findings and Impression
History: "RLQ pain"
FINDINGS:
Bowel: Dilated appendix with signs of inflammation including wall thickening, hyperenhancement, and surrounding fat stranding. No associated fluid collections or free air.
IMPRESSION:
Acute uncomplicated appendicitis.