醫(yī)學教學課件英文版：The Outline of Radiological Reports

*511TheOutlineofRadiologicalReports*512FoundationofRadiologyRadiograph['redio,ɡr?f]

animageproduceonafilmbyX-rays*513

Radiography

[redi'ɑɡr?fi]

ThetechniqueofexaminingthebodybydirectingX-raysthroughittoproduceimagesonphotographicplatesorfluorescent[fl?'r?s?nt]screens.*514CT*515MRI

*516DSA*517*518SignificanceandRequirementsThewritingofaradiodiagnosticreporthastobeapreciseworkbecauseitisnotonlyaconsultingsuggestionforcliniciansbutalsoamedicolegaldocument.Theradiologistsshouldchoosewordscarefullyandexactlyandtrytomakethereportinclarityofdescriptionandareasonableanalysis.*519TheStructureofRadiodiagnosticReports1.CommonInformation2.ExaminationTechniques3.Description4.Diagnoses5.Signature*51101.CommonInformationNameAgeSexofPatientDateofExaminationNumberofExaminationRegionsofExaminationsPositionsofX-rayRadiographs*5111ForInstanceofCommonInformation*51122.ExaminationTechniques*5113*5114

CT*5115*5116NeuroHeadDTI*5117NeuroHeadBOLDimaging*5118ForInstanceof

ExaminationTechniques*5119ForInstanceof

ExaminationTechniques*51203.Description

Thedescriptionoftheanatomicalrelationships,pathologicalchangesandradiologicalsignsofimagesisaproblemforradiologistsevenintheirownnativetongues.Tobeabletotalkproperlyonthoseprofessionalterms,firstly,topersistinextensivereadinginthosefields.*5121DescriptionofRadiologicalReports*5122BasicStructuresa.Thereis…,Thisis…,Itis…,

Thereisanodularshadowintherightpulmonaryhilum.intherightfrontallobeintherightkidneyintherightovaryintherighthumerus*5123b.X-rayplainradiographs(CTimages,MRIimages)show(display,illustrate,demonstrate…)anodularshadowintherightpulmonaryhilum.intherightfrontallobeintherightkidneyintherightovaryintherighthumerus*5124c.Anodularshadowcanbefound(shown,displayed,demonstrated,illustrated…)intherightpulmonaryhilum.intherightfrontallobeintherightkidneyintherightovaryintherighthumerus*5125

SkilledDescription

forHepaticHaemangioms

Followingadministrationofparamagneticcontrastagent,thelesionshowsacontinuousincreaseinsignalintensityandarethusvisualizedashyperintenseinthelatepostcontrastphase.Nodular,patchyenhancementofperipheralvesselsintheearlyperfusionphaseandthefill-inphenomenonondelayedscansarethetypicalchracteristicofthelesion.*5126AnatomyandRadiologyareIntrinsicallyLinkedinRadiologicalDescriptionswecannotdescribeapituitaryglandadenomawithouttalkingaboutthepituitaryglanditself,thestalk,thesella,thecarotidarteries,theopticchiasm,thecavernoussinusandthesphenoidsinus.

*5127SixFeaturesofLesions1.DistributionSomediseasesoftenpredisposeinacertainpart(parts)ofthehumanbody.Therearesomerulesofthumbforthem.Distributionsoflesionsaredepictedasanextensiveorlocalizedrange,scatteredordensestructure.

Describingthelocationoffocallesionsdependsontheorganwheretheyaresited.

*51282.NumbersandSizesoflesionsTheseoftenrelatetothecharacterizationoflesions.Solitary/singleormultiple:Ifmultiple,thepatternofdistributionmaybereported(diffuse,segmental,lobar...).Describethesizeinmillimeters.Ifmultiple,youmaymentionthelargestoneandthesmallestone.*51293.ShapesandmarginsoflesionsAfuzzymarginonapatchyshadowoftenrepresentsanacuteinflammation,whileaclearmargininastripe-likesubstanceusuallysuggestsachronicproliferation.Shape(round,oval,lobulated,irregular).Contour(smooth,irregular)and delimitationfromtheadjacentparenchyma(well-delimited/defined,poorly/illdelimited/defined).*51304.ChangesindensityorSignalIncomparisonwiththenormalsurroundingtissues,lesionsaredescribedashighdensity,lowdensityorisodensity.Homogeneous/heterogeneous· Low/highdensity/intensity· Cystic/solid/complex(US)· Searchforthepresenceofotherdifferentdensitieswithinthelesion:calcifications,fat,blood,necrosis,capsule,septa,scar.*51315.SurroundingtissuesItisimportanttoverifywhethertherearescattered“satellite”fociandalterationsofthesurroundingnormalstructures.*51326.EnhancementEnhancinglesionornon-enhancinglesionandpatternofenhancement:Evaluationin:Arterialphase/portalvenousphase/equilibriumphase/delayedphase(liver).Arterialphase/corticomedullaryphase/nephrographicphase/excretoryphase(kidney).Plus,delayedphaseifbladderneedstobeevaluated.*5133ForInstanceofDescription*5134ForInstanceofDescription*5135NormalChestRadiographHistory:Shortnessofbreathandfever.Findings:ChestPAandlateralfilmscomparedwithsimilarstudydated6September2005showsnormalcardiomediastinalsilhouette.Thecostophrenicsulciaresharp.Thelungsareclear.Therehasbeennosignificantintervalchangesincethepriorexamination.Impression:Normalchestradiograph.*5136NormalUGIStudyHistory:Abdominalpain.Technique:

DoublecontrastUGIstudyisperformedbyadministrationofthickandthinbarium.Real-timefluoroscopicexaminationiscomplimentedwithspotimagesandoverheadradiographs.Findings:*5137Patientisabletoswallowwithoutdifficulty.Contrastmaterialcoatingoftheesophagus,stomachandduodenalbulbshowsnoulcerationorabnormalcontour.Theesophagusisofnormalcaliber.Contrastmaterialtransitsintothestomachandduodenumunobstructed.Peristalticwavesareobserved.Theesophagus,stomachandduodenalbulbarepliable.Nohiatalherniaisseen.Provocativemaneuversdonotelicitgastroesophagealreflux.Impression:NormalUGIstudy.*5138NormalCTScanoftheHeadHistory:

Headache.Technique:Multipleaxialimagesoftheheadareobtainedfromtheskullbasetothehighconvexitieswithoutadministrationofintravenouscontrastagent.Nosimilarpriorstudyisavailableforcomparison.Findings:Thereisnointra-orextraaxialhemorrhage,midlineshift,ormasseffect.Thenormalgrey±whitedifferentiationispreserved.Theventricleandsulciareofexpectedsizeandmorphologyforthepatient'sage.Imagedparanasalsinusesandmastoidaircellsareclear.Impression:NormalCTscanofthehead.*5139

NormalLumbosacralSpineMRI

History:Rightradiculopathy.Technique:SagittalT1-WandT2-WimageswereperformedfromtheT12levelinferiorlytotheS2level.AxialT1-WandT2-WimageswereperformedfromtheL3levelthroughtheS1level.Findings:*5140Thealignmentofthelumbosacralspineisanatomic.Thereisnoevidenceofdisccompression.Thereisanormaldischydrationsignaldemonstrated.Theconusmedullarisisnormalinsignalintensity.AxialimagesattheL2-3level:thespinalcanalandneuralforaminaareadequatelypatent.AxialimagesattheL3-4level:thespinalcanalandneuralforaminaareadequatelypatent.AxialimagesattheL4-5level:thespinalcanalandneuralforaminaareadequatelypatent.AxialimagesattheL5-S1level:thespinalcanalandneuralforaminaareadequatelypatent.Impression:NormallumbosacralspineMRI.*5141YourFirstRadiologicalReportsinEnglishMyadviceisthatyoushouldreadradiologicalreportsasareferenceandbuildseveral“templates”reportswhichincludethemostcommonabnormalitiessothatyoucansimplychoosethesentencesthatfityourparticularcase.Onceagainwritethesentencescontainingeithernormalfindingsandcommonpathologysothatyoubecomefamiliarwiththeirspelling.*51424.DiagnosesExample1(fromseriousillnessestolessseriousones)Pneumoniaintherightupperlobe.Oldtuberculosisintheleftupperlung.Bifurcationattheanteriorendoftheleftfourthrib.*5143Example2(fromcausetoeffect)Rheumaticheartdisease:1)Mitralstenosis,2)Acutefailureoftheleftheart,3)Bilateralpleuraleffusion.*5144ForInstanceofDiagnoses*5145*51465.SignatureThesignaturerepresentsthattheradiologisthascheckedalltheaspectsoftheradiodiagnosticexaminationandthecontentofthereportcarefullyandcompletely,thus,itmustbeearnest.Thesignaturehasbeenmoreimportantintheelectricversionofaradiodiagnosticreport.Ontheonehand,ittypifiesapreciseandmethodicalmindofaradiologist.Andontheotherhand,itisafactthatthesigning