Reports

Ankle plain film

Clinical statement: []

Technique: 3 views of the [] ankle.

Comparison: []

Findings: No fracture or dislocation is seen. The ankle mortise appears intact on these nonstress views. No significant soft tissue swelling is identified.

Impression: No fracture or dislocation.

Cervical spine plain film


Technique: [] views of the cervical spine.

Comparison: []

Findings: The cervical spine is visualized from C1-C7. No prevertebral soft tissue swelling is seen. The cervical alignment is maintained without spondylolithesis. No acute fracture is identified. The vertebral body and disc space heights are preserved. The odontoid process is intact.

Impression: Unremarkable examination of the cervical spine.

Elbow plain film


Technique: [] views of the [] elbow.

Comparison: []

Findings: No fracture or dislocation is seen. No joint effusion is identified. No significant soft tissue swelling is seen.


Foot plain film


Technique: [] views of the [] foot.

Comparison: []

Findings: No fracture or dislocation is seen. No significant soft tissue swelling is identified.


Hand plain film


Technique: [] views of the [] hand.

Comparison: []

Findings: No fracture or dislocation is identified. No significant soft tissue swelling is seen.


Hip plain film


Technique: [] views of the [] hip.

Comparison: []

Findings: No fracture or dislocation is seen. The hip joint is well-maintained.


Knee plain film


Technique: [] views of the [] knee.

Comparison: []

Findings: No fracture or dislocation is seen. No joint effusion is identified. No significant soft tissue swelling is seen.


Lumbosacral spine plain film


Technique: [] views of the lumbosacral spine.

Comparison: []

Findings: The vertebral body and disc space heights are preserved. The spinal alignment is maintained without evidence of spondylolisthesis. No acute fracture is identified. No lytic or blastic lesions are seen. The sacroiliac joints are unremarkable.

Impression: Normal examination of the lumbosacral spine.

Osseous survey

Clinical Statement: []

Technique: Complete osseous survey, including [] images. Comparison: [] Findings:

Skull: No lytic or blastic lesions are seen.

Cervical Spine: No lytic or blastic lesions are seen.

Thoracic Spine: No lytic or blastic lesions are seen.

Lumbosacral Spine: No lytic or blastic lesions are seen.

Pelvis: No lytic or blastic lesions are seen.

Bilateral upper extremities: No lytic or blastic lesions are seen.

Bilateral lower extremities: No lytic or blastic lesions are seen.

Impression: No lytic or blastic lesions seen on complete osseous survey.

Chest Radiograph


Technique: PA and lateral views of the chest.

Comparison: []

Findings: The lungs are clear. There are no pleural effusions. The cardiomediastinal silhouette is within normal limits.

Impression: No acute cardiopulmonary disease.

Pelvis plain film


Technique: [] views of the pelvis.

Comparison: []

Findings: No fracture or dislocation is seen. The hips joints, sacroiliac joints, and symphysis pubis are well-maintained.


Shoulder plain film


Technique: [] views of the [] shoulder.

Comparison: []

Findings: No fracture or dislocation is identified. The glenohumeral and acromioclavicular joints are intact.


nonfusion of the first and second segments of the sacrum so that there is one additional articulated vertebra, the sacrum consisting of only four segments.

Shunt series

Used to evaluate verticuloperitoneal shunt catheters Consists of AP and lateral views of the skull, chest, and abdomen Look for shunt catheter kinking or discontinuity Catheter must be viewed in two orthogonal planes through-out its entirety Catheter tip should be identified, if possible and evaluated for pseudocyst Clinical statement: Evaluate ventriculoperitoneal shunt.

Technique: Frontal and lateral radiographs of the skull, thorax, and abdomen were obtained.

Comparison:[]

Findings: A ventriculoperitoneal shunt extends from the [] region, traverses the [] neck, [] anterior chest, [] abdomen, and terminates in the [] pelvis. The shunt catheter appears intact without evidence of fracture.

Impression: Evaluation of ventriculoperitoneal shunt without evidence of fracture

Thoracic spine plain film


Technique: [] views of the thoracic spine.

Comparison: []

Findings: The vertebral body and disc space heights are preserved. The spinal alignment is maintained without evidence of spondylolithesis. No acute fracture is identified. No lytic or blastic lesions are seen.

Impression: Normal examination of the thoracic spine.

Wrist plain film


Technique: 3 views of the [] wrist.

Comparison: []

Findings: No fracture or dislocation is identified. No significant soft tissue swelling is seen.


Thyroid ultrasound


Technique: A sonogram of the thyroid gland was performed assessing gray-scale appearance and color doppler flow.

Comparison: []

Findings:

The left lobe is normal in size measuring [ ] x [ ] x [ ] cm. The right lobe is normal in size measuring [ ] x [ ] x [ ] cm.

No nodules are seen. The isthmus is normal in size measuring [ ] in maximum AP diameter. No adjacent enlarged lymph nodes are seen.

Impression: []

Abdominal ultrasound


Technique: A sonogram of the abdomen was performed assessing gray scale appearance and color doppler flow.

Comparison: []

Findings: The liver is normal in echogencity and size, measuring approximately [ ] cm in longitudinal dimension. No focal lesions are seen. The hepatic veins and portal veins are patent with appropriate directional flow. No intrahepatic ductal dilatation is seen. The gallbladder is not distended and has normal wall thickness. No pericholecystic fluid or gallstones are visualized. The sonographic Murphy's sign is negative. The common duct is not dilated with a diameter of [ ] cm.

The visualized pancreas appears normal. No pancreatic ductal dilatation is visualized. The splenic vein is patent. The spleen is normal in echogenicity and size, measuring [] cm in longitudinal dimension. The right and left kidneys are normal in echogenicity and size, measuring [] and [] cm in longitudinal dimension, respectively. No hydronephrosis, renal mass or calculi are visualized.

The visualized portion of the inferior vena cava is unremarkable. No abdominal aortic aneurysm is identified.

Impression: []

Chest CT


Technique: A chest CT was performed utilizing contiguous axial images from the thoracic inlet to the level of the adrenal glands [with/without] the use of intravenous contrast.

Comparison: []

Findings: No thoracic lymphadenopathy is present. No pleural or pericardial effusion is seen. The heart is normal in size.

The lungs are clear. The trachea and central airways are patent.

Limited evaluation of the upper abdomen is unremarkable.

Impression: Normal chest CT.

Scrotal ultrasound


Technique: A sonogram of the scrotum was performed assessing gray scale appearance and color doppler flow.

Comparison: []

Findings:

The right testis measures [ ] x [ ] x [ ] cm and is of normal echotexture. No focal right testicular parenchymal lesions are visualized. Testicular arterial flow is visualized. The right epididymal head is normal in size measuring [ ] cm. The right epididymal body is normal in size measuring [ ] cm. No right hydrocele or varicocele is seen.

The left testis measures [ ] cm and is of normal echotexture. No focal left testicular parenchymal lesions are visualized. Testicular arterial flow is visualized. The left epididymal head is normal in size measuring [ ] cm. The left epididymal body is normal in size measuring [ ] cm. No left hydrocele or varicocele is seen.

Impression: []

Renal colic protocol CT sample dictation


Technique: A CT of the abdomen and pelvis was performed utilizing contiguous axial images without the use of oral or intravenous contrast.

Comparison: []

Findings: []

The liver, gallbladder, common bile duct, spleen, pancreas and adrenal glands are unremarkable.. No radiopaque renal, ureteral or urinary bladder calculi are visualized.

The bowel is unremarkable. No abdominal or pelvic lymphadenopathy or ascites is identified.

The urinary bladder and [uterus/prostate] are unremarkable. [No adnexal masses are seen.]

Impression: []

Scrotal ultrasound sample dictationClinical statement: []

Technique: A sonogram of the scrotum was performed assessing gray scale appearance and color doppler flow.

Comparison: []

Findings:

The right testis measures [ ] x [ ] x [ ] cm and is of normal echotexture. No focal right testicular parenchymal lesions are visualized. Testicular arterial flow is visualized. The right epididymal head is normal in size measuring [ ] cm. The right epididymal body is normal in size measuring [ ] cm. No right hydrocele or varicocele is seen.

The left testis measures [ ] cm and is of normal echotexture. No focal left testicular parenchymal lesions are visualized. Testicular arterial flow is visualized. The left epididymal head is normal in size measuring [ ] cm. The left epididymal body is normal in size measuring [ ] cm. No left hydrocele or varicocele is seen.

Impression: []

Voiding cystourethrogram sample dictation


Technique: Under sterile conditions, a pediatric straight catheter was inserted into the urinary bladder and contrast was instilled.

Comparison: []

Findings:

A scout film of the abdomen is unremarkable. The bladder filled normally and was smooth in contour. There is no vesicoureteral reflux. A normal [female/male] urethra was identified during voiding.

Impression: Normal VCUG without evidence of vesicoureteral reflux.

BIRADS 1 (fatty, no comparison) sample dictation

Clinical Indication: Screening mammography. Last clinical breast exam: [ ]

Findings:

No prior films are currently available for comparison. If any prior films can be submitted, comparison will be performed and an addendum to this report will be issued.

The breast tissue is predominantly fatty. No suspicious masses or suspicious clusters of microcalcifications are seen.

Impression:

No mammographic evidence of malignancy. In the absence of clinical findings, a screening mammogram should be obtained in 1 year.

BIRADS 1: Negative

BIRADS 1 (fatty, comparison) sample dictation


Findings:

Comparison is made with [ ]

The breast tissue is predominantly fatty. No developing masses or suspicious clusters of microcalcifications are seen.

Impression:


BIRADS 1: Negative

BIRADS 0 sample dictationFrom RadsWiki

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TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED: []

Clinical Indication: Screening mammography. Last clinical breast exam: [ ].

Findings:

[Comparison is made with prior mammograms dated; No prior films are currently available for comparison. If any prior films can be submitted, comparison will be performed and an addendum to this report will be issued.]

[The breasts are almost entirely fatty.; The breast tissue is composed of scattered fibroglandular densities.;; The breast tissue is extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.]

[ ]

[No suspicious masses or suspicious clusters of microcalcifications are seen in the left/right breast.]

Impression:

[]

Recommendation: [Comparison with prior mammograms is strongly recommended. If the patient is unable to obtain prior mammograms for comparison, the patient will be recalled for additional imaging of the [ ]

BIRADS 0: Incomplete; need additional imaging evaluation

BIRADS 1 (heterogenous, comparison) sample dictationFrom RadsWiki


TECHNIQUE: SCREENING [DIGITAL] MAMMOGRAPHY DATED [ ]


Findings:

Comparison is made with [ ]

The breast tissue is heterogeneously dense, which may lower the sensitivity of mammography. No developing masses or suspicious clusters of microcalcifications are seen.

Impression:


BIRADS 1: Negative

Unilateral right mammogram status post left mastectomy sample dictationFrom RadsWiki


CLINICAL HISTORY: [ ] year old woman status post left mastectomy for carcinoma in [ ]. The patient is now referred for follow up right mammogram. [ ]

TECHNIQUE: Unilateral right mammogram dated [ ]

COMPARISON: [ ]

FINDINGS:

The right breast is [almost entirely fatty.; composed of scattered fibroglandular densities.; heterogeneously dense, which may lower the sensitivity of mammography.; extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.]

No mammographically suspicious mass or suspicious cluster of calcifications are seen in the right breast.

IMPRESSION:

No mammographic evidence of malignancy in the right breast.

RECOMMENDATION:

Unilateral right mammogram in one year.

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: Benign findings]

Unilateral right mammogram status post left mastectomy sample dictationFrom RadsWiki


CLINICAL HISTORY: [ ] year old woman status post left mastectomy for carcinoma in [ ]. The patient is now referred for follow up right mammogram. [ ]

TECHNIQUE: Unilateral right mammogram dated [ ]

COMPARISON: [ ]

FINDINGS:

The right breast is [almost entirely fatty.; composed of scattered fibroglandular densities.; heterogeneously dense, which may lower the sensitivity of mammography.; extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.]

No mammographically suspicious mass or suspicious cluster of calcifications are seen in the right breast.

IMPRESSION:

No mammographic evidence of malignancy in the right breast.

RECOMMENDATION:

Unilateral right mammogram in one year.

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: Benign findings]

Hysterosalpingogram sample dictationClinical Statement: []

Technique: A standard hysterosalpingogram was performed.

Comparison: []

Findings:

The endometrial cavity is normal in contour without any filling defects.

Contrast is seen in the fallopian tubes bilaterally which are normal in course and caliber. There is free intraperitoneal spill of contrast bilaterally.

Impression: Normal hysterosalpingogram.

Small bowel series sample dictationFrom RadsWiki


[edit] Sample Dictation


Technique: Standard barium small bowel series was performed with multiple overhead radiographs. In addition, the small bowel was examined fluoroscopically intermittently throughout the examination.

Comparison: []

Findings: The small bowel is of normal course and caliber. No intrinsic or extrinsic mass lesions are identified. The transit time is within normal limits. The terminal ileum appears normal.

Impression: Unremarkable small bowel series.

Small bowel series sample dictationClinical statement: []

Technique: Standard barium small bowel series was performed with multiple overhead radiographs. In addition, the small bowel was examined fluoroscopically intermittently throughout the examination.

Comparison: []

Findings: The small bowel is of normal course and caliber. No intrinsic or extrinsic mass lesions are identified. The transit time is within normal limits. The terminal ileum appears normal.

Impression: Unremarkable small bowel series.

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How to Read a Head CT

Look at scout images

Look at brain windows (W 155 L 40)

Look at stroke windows (W 30 L 30)

Look at subdural windows (W 150 L 5)

Look at bone windows (W 3000 L 570)

Ultrasound core biopsy sample dictationFrom RadsWiki


CLINICAL HISTORY: [ ] year old woman referred for ultrasound-guided biopsy of a mass in the [right/left] breast. The lesion was noted on previous ultrasound performed at [ ] on [date]. Recent mammogram performed at [ ] on [date] [demostrated/failed to demonstrate] the lesion.

Technique: [ ] breast ultrasound guided core biopsy dated [ ].

PROCEDURE:

Preliminary ultrasound evaluation of the [right/left] breast with special attention to the area of [sonographic/mammographic/palpable] concern, confirms the presence of a [ ] x [ ] cm mass at the [ ] o'clock position, approximately [ ] cm from the nipple, at a depth of [ ] cm from the skin.

Following universal protocol, patient and site verification was performed with a "time out" prior to the procedure. Informed consent was obtained. The patient was positioned in the supine oblique position, and the lesion was localized with real-time sonography. The skin was cleansed with Chloraprep. [ ] cc's of 1% Lidocaine was used for local anesthesia. A [lateral/medial/oblique] approach to the target was used. An 18-gauge needle, secured to a

spring-loaded device, was advanced to the preselected target. A total of [ ] biopsy specimens were obtained, with pre- and post-fire images documenting needle placement for each pass. Specimens were sent for pathologic analysis, results pending.

Following the procedure, the wound was cleansed and compressed. Steri-strips and sterile gauze were applied and the patient was given post-biopsy instructions. The patient tolerated the procedure well and left the department in good condition.

Dr. [ ] was in attendance during the entire procedure.

IMPRESSION

Ultrasound-guided core biopsy of [right/left] breast mass. Pathology pending

Needle localization (ultrasound) sample dictationFrom RadsWiki


CLINICAL HISTORY: [ ] year old woman referred for needle localization of a mass in the [right/left] breast. The lesion was noted on previous ultrasound performed at [ ] on [ ]. Recent mammogram performed at [ ] on [ ] revealed [ ].

Technique: Needle localization under ultrasound guidance, specimen radiography

PROCEDURE: Following universal protocol, patient and site verification was performed with a "time out" prior to the procedure. Preliminary ultrasound of the [right/left] breast with special attention to the area of sonographic concern, confirms the presence of a [ ] x [ ] cm mass at the [ ] o'clock axis, [ ] cm from the nipple.

Informed consent was obtained. The patient was positioned in the supine oblique position. The skin was cleansed. 0.2 cc 1% Lidocaine was used for local anesthesia. Using a [lateral/medial/superior/inferior] approach, a [ ] needle/wire assembly was used to localize the target under real-time sonographic guidance. A post-localization mammographic view was obtained, and sent with the patient to the OR.

The patient tolerated the procedure well and left the department in good condition.

A surgical specimen submitted for radiography demonstrates the targeted lesion to be within the specimen. The [ ] wire is intact. Dr. [ ] was notified of these findings at the time of surgery.

IMPRESSION: Ultrasound-guided needle localization and documented excision [left/right] breast mass.

Bone age sample dictationFrom RadsWiki


Contents

[hide]

1 Discussion 2 Sample Dictation 3 Standard Views 4 Greulich and Pyle

o 4.1 MALE o 4.2 FEMALE

The most commonly used method is based on a single x-ray of the fingers, hand, and wrist.

A hand is easily x-rayed with minimal radiation and shows many bones in a single view. The bones in the x-ray are compared to the bones of a standard atlas, usually "Greulich

and Pyle"


Technique: PA view of the left hand.

Comparison: []

Findings: The patients chronological age is X years. His bone age is most compatible with the

standary of A years. The mean bone of an individual of this chronological age is B years, with a standard deviation of C months.

Impression: Normal/Advanced/Delayed bone age with respect to the age and gender matched standards of Greulich and Pyle.

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