The four parts of a radiology report

by Allison Zwingenberger on April 13, 2007

The radiology report

Each radiological study is a diagnostic test. The clinician has already examined the animal and has a list of differential diagnoses in mind. The goal of the imaging procedure is to rule in disease, rule out disease, or discover new information.

The report on any diagnostic imaging study needs to be structured and concise. For any written or oral report, including the oral board exams, I like to break down the radiology report into four sections. A good description, a radiologic diagnosis, a ranked differential diagnosis, and further recommendations are what you need.

Description

The first part of your report should describe the radiologic findings. I like to use a systematic approach, working from the outside of the radiograph to the inside in. First evaluate technique and positioning, and how it could affect your interpretation. For example, if the radiograph is underexposed, that could explain a finding of poor peritoneal detail. Radiologic findings include classic Roentgen signs such as size, shape, opacity, number and position of organs. If you are evaluating the liver, you might say that the liver margin extends beyond the costal arch, and the margins are rounded. Describe your findings first, then move on to the next step.

Radiographic Diagnosis

The radiographic diagnosis is a summary of your findings. Radiographic diagnoses are specific terms that describe your observations in a concise and more concrete form. The radiographic diagnosis that we can make from the description of the liver changes is hepatomegaly. There may be more than one radiographic diagnosis on a set of images, and this summary helps you to gather them all together to consider the cause.

Differential Diagnosis

The next step is to make a prioritized list of differential diagnoses for your findings. If you have one main finding, list differentials that could be causes. Hepatomegaly could be caused by hyperadrenocorticism, diabetes, inflammation, toxicity, and other causes. When you have more than one finding, like an abdominal mass and free peritoneal gas, try to make a story that ties both of them together, like a gastrointestinal mass with rupture and septic peritonitis. If one explanation doesn’t make sense, you can list differentials for both findings. It’s also helpful to list the most significant findings first and incidental findings last.

Recommendations

Your list of differential diagnoses may be different than the original set that the clinician ordered the imaging study with. You may have come up with a confident diagnosis and obvious plan, such as surgery in the case of septic peritonitis. If there are several possible causes for the findings, suggest further imaging studies that could help to narrow the list. Ultrasound, cross-sectional imaging, and fine needle aspirates of lesions are all possibilities.

The concise report

Following these four steps will lead you to a concise, structured report to help you and the clinician determine what the next step is. It’s essential in clincial and academic practice, as well as for the oral board exams.

The four parts of a radiology report:

  • Description of findings
  • Radiographic diagnosis
  • Ranked differential diagnosis
  • Next steps

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