Show Menu
Cheatography
  1. Home >
  2. Home and Health >

Radiological Report Writing Cheat Sheet (DRAFT) by

Report writing - components

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Components of an x-ray report

Clinical inform­ation:
Age, gender, name, ID#, chief complaint, hx of trauma, medical history
Radiol­ogical findings
ABCs
Impres­sions
Summary of the issue
Recomm­end­ations
Management of what was found

ABCS

A
Alignment
B
Bone
C
Cartilage
S
Soft Tissue
Impression

Alignment

Lateral View
Cranio­cer­vical junction
 
McGregor's line and Chambe­rlain's line
 
ADI
 
Cervical and lumbar lordosis
 
Tx kyphosis
 
George's line, anterior VB line, pillar line, spinol­aminar line
APOM and APLC, AP Tx, AP Lx
Lateral offset @ C1 lateral masses - overhang
 
Scoliosis
 
Pelvic unleveling
McGregor's line: Posterior margin of hard palate to inferior surface of occipital bone
Normal Tip of Dens should not be over the line by >8mm males and >10mm females
Chambe­rlain's line: Posterior Margin of hard palate to opisthion (if this cannot be seen, use Mcgreg­or's) - should not be >3mm above this line

ADI: Posterior margin of C1 anterior tubercle to anterior surface of dens.
Normal: Adult: 1-3mm Child: 1-5mm

Bone

Things to consider:
Density - adequate? Decreased? Increased?
Number - congenital anomalies? Block vertebrae? Cx ribs? SBO? LS transi­tional segment
Integrity - Height loss - compre­ssion vs burst f# Lytic lesion­s?B­lastic lesions? Pedicles

Cartilage

Things to consider:
Cx: Discs, uncove­rtebral joints (unici­nates), facet joints, ALL, PLL, C1-2 joints
Tx: Discs, facet joints, costov­ert­ebral joints
Lx: Discs, facet joints, SI joints, femoro­-ac­eta­bular joints

Soft Tissues

Trachea
Prever­tebral soft tissues
Lung apices
Subman­dibular soft tissues
Lungs
Abdomen and pelvis
Retrop­har­yngeal interspace - from anterior inferior body of C2 - Posterior air shadow of pharynx
Should be <6mm

Retrot­racheal Interspace- from anterior inferior angle of C6 body - posterior air shadow of trachea
Should be <20mm

CATBITES

In impression section
C: Congenital -anomalies + normal variants
A: Arthritis - degene­rative, inflam­matory, metabolic
T: Trauma
B: Blood - haemat­olo­gical and vascular
I: Infection - suppur­ative and non-su­ppu­rative
T: Tumour - benign, malignant and tumour­-like
E: Endocrine - metabolic, nutrit­ional and endocrine
S: Soft tissues

Tips

Keep it short and sweet
Complete, narrative sentences
Split paragraphs into pathologic and normal findings
Present test for x-ray findings + past tense for what was done at the time
"­There is" should not be used - get to the point
Listen to request - if there is a request to rule out/in a pathology, highlight whether or not there is signs
Most important findings first
Inductive logic - observ­ations first and conclu­sions last
Only report incidental observ­ations when they are relevant
Should be clear whether diagno­sis­/im­pre­ssion is definite - state degree of certainty
Use measur­ements in cms or degrees, when it cannot be use use - slight moderate or severe
Avoid using pure radiol­ogical terms - use descri­ptive terms