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How To Compose A Radiology Report: Guidelines
- not appreciated
- obviously present
- should have been identified
Kilroy was here
Origin When the war came in 1941, a shipyard inspector, James J Kilroy, wanted to make sure that his boss knew he was on the job. To show his superiors how efficient he was, he chalked his name on the rivets that were his responsibility. Soldiers on the troop ships took up this catchy signature - and the rest is history. Many centers have gone to filmless radiography, with images transmitted to monitors for viewing. Such systems need a system to mark the films. Kilroy was here.
Smith JP. Risk management for the radiologist. AJR 1987; 149:641-643.
Clinger NJ, Hunter TB , Hillman BJ. Radiology reporting: attitudes of referring physicians. Radiology 1988; 169:825-826.
Berlin L. Reporting the "missed" radiologic diagnosis: medicolegal and ethical considerations. Radiology 1994; 192:183-187.
McLoughlin RF, So CB, Gray RR , Brandt R. Radiology reports: how much descriptive detail is enough? AJR 1995; 165:803-806.
Berlin L. Communication of the urgent finding. AJR 1996; 166:513-515.
Sobel JL, et al. Information content and clarity of radiologists' reports for chest radiography. Acad Radiol 1996; 3:709-717.
Berlin L. Radiology reports. AJRl 1997; 169:943-946.
Berlin L. Malpractice issues in radiology. Admitting mistakes. AJR 1999; 172:879-884.
Cascade PN , Berlin L. Malpractice issues in radiology. American College of Radiology Standard for Communication. AJR 1999; 173:1439-1442.
Berlin L. Comparing new radiographs with those obtained previously. AJR 1999; 172:3-6.
Berlin L. Malpractice issues in radiology. Alliterative errors. AJR 2000; 174:925-931.
Berlin L. Must new radiographs be compared with all previous radiographs, or only with the most recently obtained radiographs? AJR 2000; 174:611-615.
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The written radiology report
Dr. Wilcox is an Interventional Radiologist, East Texas Radiological Consultants, Athens, TX.
The written radiology report is the most critical component of the service provided by a radiologist. It constitutes the formal documentation and communication of the results of a radiologic study or procedure. 1 The reports are usually dictated by a trained radiologist, but reports may vary greatly in style, format, and effectiveness. A major cause of litigation against radiologists is failure to effectively communicate results. 2,3 As radiologists, it is time that we look at this issue with renewed diligence.
Part of the problem with radiology reports arises because we do not really understand how important this document has become to the non-radiologist caregiver. 4 This lapse is more understandable when you realize that most major radiology textbooks do not address the subject of report composition. This would be equivalent to a journalism textbook without a chapter on how to write an article. But journalism and radiology have a lot in common. Both professions require spending a great deal of time gathering "facts" and "data" and then reporting that material in written form for a reader.
The purpose of this article is to help radiologists improve the quality of their written radiology reports by reviewing the components of a report, addressing grammar and writing style, and considering appropriate standardization.
One of the 3 most common reasons for malpractice suits against radiologists is failure to communicate results clearly and effectively. 2,3 Poor communication is a common reason patients choose to sue the doctor. 5,6 In some situations, such as mammograms, it is helpful to give a copy of the report directly to the patient, which makes it even more important that the report is clear and understandable. 6,7 If a report is written so that a patient can understand what is said, it is much more likely that a healthcare provider, who depends upon the report to make decisions concerning patient management, will also understand the report. 8
In order to achieve clear communication, the radiologist should be aware of the intended reader of the report and how that reader will understand what is written. Most often, the reader of the radiology report is the individual responsible for providing direct patient care. In some cases, the reader will be the patient. The report should be written with these readers in mind. 9 The use of difficult or ambiguous terms should be avoided. Esoteric terms and language not commonly understood will detract from effective communication. 10 The radiology report may provide information critical to patient care, but these findings can be helpful only if the reader understands what is said. Unfortunately, the proper use of grammar becomes a part of understandable communication. 9,11 Table 1 lists some guidelines that can help radiologists create an understandable report.
Effective report writing means that useful information obtained from the radiologic study will be transmitted clearly, concisely, and unambiguously. The report is the written communication of the radiologist's interpretation, discussion, and conclusions about the radiologic study. The written report is frequently the only source of communication of these results. The report should communicate relevant information about diagnosis, condition, response to therapy, and/or results of a procedure performed. 12
The written report should also answer any clinical question raised by the requesting patient-care provider that is relevant to the radiologic study. For example, if the study was requested with the clinical information "cough and fever," then the report should specifically address whether or not the findings are consistent with pneumonia.
Ownership of the radiology report, its legal status, and its relationship to malpractice liability is sometimes misunderstood and can contribute to a confusing report. Ownership of the written report is held by the organization providing the radiologic service; this organization may be a hospital, clinic, health maintenance organization, imaging center, or private radiology office. Maintenance and security of the original record is the responsibility of the organization or individual who performed the imaging examination. Since the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all patients have a legal right to a copy of their report.
The radiology report may generally be viewed as part of the medical record. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers the radiology report to be part of the medical record because it documents the results of a radiologic test or procedure. 13 In addition, hospitals have specific policies regarding the radiology report as part of the medical record. If the medical record is subpoenaed or when statutory regulations require specific documentation, the medical record can be regarded as a "legal document."
Malpractice suits are based on either damages or breach-of-contract issues. The most common cause of malpractice suits against radiologists is "failure to diagnose." 14 Failure to diagnose may become the basis of malpractice if this failure is the proximate cause of injury or damages. 15 The failure to diagnose may be the direct result of the written report. The second most common cause of malpractice suits against radiologists is "failure to clearly communicate the results." 14
The report can be the proximate cause of damages if it failed to effectively communicate important information about the patient's condition. 16 It is this aspect of liability risk that should also motivate radiologists to look at their reports as "communications" to referring physicians and patients and to compose them accordingly.
The key to a clear and concise radiology report that will provide reliable high-quality communication is a coherent format. The radiology report is a diagnostic test result that should stand independent of the individual interpreting radiologist. The quality of the report should not vary as a result of there being different interpreting radiologists. This is a key principle in statistical quality control. The control of variation reduces liability risk because it ensures that important issues are addressed systematically. 17 Using a standard format will significantly improve the ability of the report to communicate effectively. Variations in the report format create confusion for the reader, whereas a consistent location for the results, discussion, and conclusions assists the reader in understanding the report and its clinical implications.
The scientific report format is a practical choice for the radiology report. 11 This format is used by major scientific journals, is familiar to most physicians, and follows the general outline recommended by the American College of Radiology (ACR). 12 It also supports the notion that the radiologic study is a "scientific test." Table 2 presents a side-by-side comparison of the scientific report format and a corresponding radiology report format.
In most situations, the title of the radiologic report is already standardized. In some institutions, this title is provided to the transcriptionist with the request. However, it is customary to include the report title for the purpose of identification. The name of the study that is used during ordering or scheduling the study may not be the desired title for the official report. The correct title of the study actually performed should be clarified at the time of dictation. Complicated procedures, such as arteriograms, biopsies, or drainage procedures, may require a statement of the title at the time of report dictation.
With many standard studies, a stated indication, or history, is not necessary in the written report. Requirements for an appropriate indication for a "test" do not necessarily require documentation of that indication within the report. In some institutions, the indication, or reason for the examination, is part of the request for the study and is automatically included in the heading of the report. However, this information may or may not represent the true indication for the study. As the consultant, the radiologist is responsible for determining the appropriateness of the study. Often, the real reason for the study is determined from information from the patient's chart or from a verbal discussion with the referring provider. Therefore, recapitulation of the indication for the study at the time of the report dictation is appropriate because it will document the actual reason the study was performed.
In addition, many third-party payers and Medicare now require an appropriate indication before they will reimburse for a study. Therefore, the radiologist is responsible for ensuring that the study was performed for an appropriate reason. The ACR Standards also include this requirement and even suggest including the corresponding ICD-9 diagnosis code in the report. 12 This can greatly expedite billing.
The indication should be a simple, concise statement of the reason for the study and/or applicable clinical information or diagnosis. A clear understanding of the indication may also clarify appropriate clinical questions that should be addressed by the study. For example, a chest radiograph requested for "cough and fever" implies the question, "Does this study indicate the presence of pneumonia?"
Even without a stated reason for the study, it is the radiologist's responsibility to identify the appropriate indication. This may be as simple as the recognition of the implied indication as understood by the context of the study and does not necessarily need to be included in the report. This information may also be available from the patient, the patient's chart, or the referring provider. This information should be pursued with reasonable thoroughness, as it may significantly change the focus of the study.
Every radiologic study has a procedure associated with performing the examination. For most routine studies, the procedure is implied by the title. For example, a routine study such as a "PA & LAT Chest," by accepted use, implies the procedure (posteroanterior and lateral chest radiograph), and a separate "Procedure" section of the report is not necessary. However, a separate "Procedure" section may be convenient to document informed consent, technical limitations, drugs, and isotopes or contrast material associated with the study. Frequently, reports for invasive procedures are best organized in a separate "Procedure" section.
Findings and discussion
The "Findings and Discussion" section of the report includes the description of the results of the study, relevant information from previous studies, pertinent clinical information, and any discussion. The discussion should explain the relationship of the results, previous studies, clinical information, and the reasoning supporting the radiologist's conclusions. However, the statements in this section should be clear and concise. Long, wordy reports are less likely to be read by the intended reader. 18
Approaching the radiologic study as if it were a scientific test will help limit the findings that need to be described. To do this, we assume a "null hypothesis" or we anticipate that the findings will fall within the expected range of normal for the given population. Therefore, it is necessary to describe only those findings that are abnormal and disprove the null hypothesis. These are referred to as positive findings. The exception occurs when a clinical question implies the possible presence of a specific abnormality. This introduces a positive hypothesis that the findings will document the questioned abnormality. In this case, normal findings that refute the presence of the questioned abnormality should be described and are referred to as pertinent negatives.
This section of the report must be organized in an orderly format so that the reader will understand the basis of the final conclusions and impressions. The reader should be able to find support in the "Findings and Discussion" section for each item listed in the "Impression" section.
The abstract is the summary of a scientific report. In a radiology report, the summary has been referred to as the "Impression," "Conclusion," or "Diagnosis" section. Sometimes this summary is an impression, sometimes it is a conclusion or diagnosis, and sometimes it is a concise statement of the findings. Practice patterns seem to favor "Impression" for the name of this section of the report.
In a large survey, >50% of referring physicians read only the "Impression" section of a radiology report! 18 This places great importance on this section of the report and emphasizes the need to view this section as a summary.
The common practice of using a numbered list for the "Impression" section helps produce a concise summation. Numbered statements or phrases should be ordered logically to make use of implied ranking. Statements in the numbered list should maintain a parallel structure-that is, if complete sentences are used, then complete sentences should be used throughout the list, or if phrases are used, then phrases should be used throughout. For clarity, it is best to limit each numbered item to a single sentence or phrase.
The "Impression" section is a list of summary statements that includes both conclusions about the radiographic study and recommendations for further evaluation and patient management. Recommendations are appropriate if the radiologist is knowledgeable about what is being recommended and if the recommendation will improve the care of the patient. Recommendations are based on the results of the radiologic study and the experience of the individual radiologist. The range of appropriate recommendations should be limited to the scope of knowledge of the individual radiologist. The use of appropriate recommendations can greatly contribute to the management of patient care and can provide consultative information that may not otherwise be available. However, the use of recommendations with the misguided notion that it is effective risk management should be avoided.
The "Impression" section is the most commonly read portion of the radiology report and is generally considered to be a summary of the study. In addition, this section may be all that is required in certain routine "normal" studies. Consequently, the "Impression" section is the most important part of the radiologic report.
Footnotes to the report
Other, more timely forms of communication of the report are also important to good radiology practice. Phone, fax, and email communication of serious, time-critical, or life-threatening information is becoming the standard of practice, and documentation of these communications is good risk management. Since these forms of communication are separate from the report itself, it is convenient to use a postscript or footnote to document such communication. A short postscript at the end of the written report is sufficient. Here are some examples:
"P.S. Dr. Doctor was contacted by phone at 1300 on 1/1/01 and the results discussed";
"P.S. Fax of report sent to Dr. Doctor";
"P.S. A copy of the report was sent by email to Dr. Doctor"; or
"P.S. Patient contacted by telephone and informed of results and the need for follow-up."
The written radiology report is the critical service of radiology and should provide clear and concise communication that is understandable by the intended reader. Since increasingly more often the patient is the reader of the report, it is even more important to keep the report clear and concise. Additionally, failure to clearly communicate results continues to be a leading cause of delayed diagnosis and resultant lawsuits. It is time to take a new and positive look at the radiology report from a different perspective. Efforts to make the radiology report an effective means of communication that is independent of individual radiologists and that focuses on the intended readers can contribute to both improved patient care and reduced liability risk.
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How to Read Your Radiology Report
Your healthcare provider (usually a doctor, nurse practitioner, or physician assistant) sometimes uses medical imaging to diagnose and treat diseases they think you may have. A radiologist is a doctor who supervises these exams, reads and interprets the images, and writes a report for your healthcare provider. This report may contain complex words and information. If you have any questions, be sure to talk to your provider or ask to speak to a radiologist.
Electronic Health Records
Sections of the radiology report, additional information.
The radiologist writes the report for your provider who ordered the exam. Typically, the radiologist sends the report to the person who ordered your test, who then delivers the results to you.
Many patients can now access their electronic health records online. These records include radiology reports. Online access to your health records may help you make more informed decisions about your healthcare. In addition, online access lets you share your radiology reports with other doctors electronically. This may increase the safety, quality, and efficiency of your care.
In most radiology practices, the radiologist still writes the report using medical terms that your healthcare provider will understand. However, these terms may be confusing for you as a patient. The information below helps explain the typical parts of a radiology report.
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Type of exam
This section usually shows the date, time, and type of exam.
- Computed tomography (CT) of the abdomen and pelvis with intravenous and oral contrast performed January 10th, 2022.
History/Reason for exam
This section usually lists the information that your ordering provider has listed for the radiologist when they ordered your exam. It allows your ordering provider to explain what symptoms you are having and why they are ordering the radiology test. This helps the Radiologist accurately interpret your test and focus the report on your symptoms and past medical history. Sometimes the radiologist who reads your exam will also add information that they find in your chart or forms that you fill out before your imaging test.
- 64-year-old female with a history of breast cancer and new onset abdominal pain.
Sometimes, the radiologist will compare the new imaging exam with any available previous exams. If so, the doctor will list them here. Comparisons usually involve exams of the same body area and exam type. It is always a good idea to get any prior imaging exams from other hospitals/facilities and provide them to the radiology department where you are having your test. Having these older exams can be very helpful to the radiologist.
- Comparison is made to a CT scan of the abdomen and pelvis performed August 24, 2013.
This section describes how the exam was done and whether contrast was injected in your vein. Because it is used for documentation purposes, this section is not typically useful for you or your doctor. However, it can be very helpful to a radiologist for any future exam if needed.
- Imaging was performed from the lung bases through the pubic symphysis following the administration of intravenous and oral contrast. Coronal and Sagittal reformatted images were evaluated.
This section lists what the radiologist saw in each area of the body in the exam. Your radiologist notes whether they think the area to be normal, abnormal, or potentially abnormal. Sometimes an exam covers an area of the body but does not discuss any findings. This usually means that the radiologist looked but did not find any problems to tell your doctor. Some radiologists will report things in paragraph form, while others use a reporting style where each organ or region of the body is listed as a line with the findings. If the radiologist does not see anything concerning it may say “normal” or “unremarkable.”
- Lung bases: No pulmonary nodules or evidence of pneumonia.
- Cardiac: Base of heart is within normal limits. No pericardial effusion.
- Liver: Normal size and contour. There is a new 2 cm hypoattenuating focus in segment 8. Gallbadder is surgically absent.
- Biliary: No intra or extrahepatic biliary dilation.
- Spleen: Unremarkable.
- Pancreas: Normal.
- Kidneys and Adrenals: No masses, stones or hydronephrosis. No adrenal nodules.
- Lymph nodes: No lymphadenopathy.
- Bowel: No dilation or wall thickening.
- Bladder: Normal.
- Uterus and Adnexa: The uterus and bilateral ovaries are within normal limits for age.
- Bones: No aggressive osseous lesions. Degenerative changes are present in the spine.
- Soft Tissues: Bilateral fat and bowel containing inguinal hernias are again noted.
- Other: No free fluid within the pelvis.
In this section, the radiologist summarizes the findings and reports the most important findings that they see and possible causes (this is called a differential diagnosis) for those findings. This section offers the most important information for decision-making. Therefore, it is the most important part of the radiology report for you and your doctor.
For an abnormal finding, the radiologist may recommend:
- other imaging tests that can help better assess the finding or getting a follow up imaging test to relook at the finding after a period of time.
- combining the finding with clinical symptoms or laboratory test results.
- comparing the finding with any other imaging studies that the radiologist interpreting your test does not have access to. This is common when you have imaging tests done at different facilities or hospitals.
For a potentially abnormal finding, the radiologist may make any of the above recommendations.
Sometimes the report does not answer the clinical question, and more exams may be needed. More exams may be necessary to follow-up on a suspicious or questionable finding.
- No findings on the current CT to account for the patient's clinical complaint of abdominal pain.
- There is a new 2 cm lesion in the liver which is indeterminate (cannot be definitively diagnosed by the study).
- RECOMMENDATION: Given the patient's personal history of breast cancer, an MRI of the liver is recommended to better characterize the indeterminate liver lesion to exclude the possibility of metastases (or cancer spread).
Once the report is complete, the radiologist signs it, and sends the report to your physician. Your doctor will then discuss the results with you.
Sometimes, you may have questions about your report that your physician cannot answer. If so, talk to your facility's imaging staff. Many radiologists are happy to answer your questions.
This page was reviewed on June 01, 2022
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Lumbar X-ray Interpretation – OSCE Guide
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Lumbar spine X-rays are one of the most commonly requested radiographic investigations of the spine, however, it should be noted that projectional radiography has limitations and other imaging modalities such as MRI and CT should be considered if further evaluation is required.
A lumbar spine X-ray is a picture of the vertebrae in the lower part of the spine . This area includes the lumbar region and the sacrum . It is important to remember that lumbar spine X-rays involve a significant radiation dose (approximately 70 chest X-rays). The relevant literature suggests that lumbar spine X-rays are not routinely indicated for uncomplicated back pain which resolves in about 90% of cases within 2 months, regardless of treatment.
Indications for a lumbar spine X-ray
Appropriate clinical indications for lumbar spine X-ray include: 1
- Significant trauma (not “lifting something” or “bending to pick up something” etc)
- Age less than 20 or greater than 50
- Past medical history of malignancy, ankylosing spondylitis or osteoporosis
- Chronic corticosteroid use (increased risk of fracture)
- An episode of back pain ongoing for 6 weeks or longer without improvement
Confirm the details
Begin by confirming you have the correct patient and the correct radiograph by assessing the following:
- Patient details (name, date of birth, unique identification number)
- Date and time the radiograph was taken
If previous radiographs are available, these should also be reviewed to provide a point of reference.
Acquire all necessary views
There are two standard projections produced when a lumbar spinal X-ray is performed:
- Anterior-posterior (AP)/posterior-anterior (PA)
In the case of trauma , additional views can be sought including oblique and horizontal beam lateral views .
Views and adequacy
In a lateral view , the entire lumbar spine should be visible from T12-S1 .
Lateral views are particularly useful for identifying fractures . Each vertebra (highlighted in yellow) should be examined looking for a loss of height which could indicate a compression fracture commonly associated with osteoporosis (see fractures section below).
Compression fractures are often seen in the upper lumbar or lower thoracic vertebrae.
Anterior-posterior (AP)/posterior-anterior (PA)
In an AP/PA view , the entire lumbar spine should be visible from T12 superiorly and the sacrum inferiorly.
The spinous processes (red) should be central and there should be equal distance between transverse processes (green). Transverse processes are often obscured by gas from the abdomen.
Spinal imaging should be taken erect in the non-trauma setting to give a functional overview of the lumbar spine. Patients with a suspected spinal injury must remain immobilised in the supine position .
There are multiple lines that should be assessed across each of the two typical radiographic views of the lumbar spine (AP/PA & lateral). These lines should run uninterrupted in healthy individuals.
On the AP/PA view check that the vertebral bodies and spinous processes are aligned .
On the lateral view , check the alignment of the vertebral bodies .
Disruption of any of these lines may indicate an underlying fracture .
A structured approach to lumbar spine X-ray interpretation is essential.
Assess alignment of the vertebral bodies and spinous processes including the lines discussed above and the distance between spinous processes.
Inspect for loss of vertebral height :
- The height of vertebral bodies should be equal in healthy individuals
- Loss of vertebral height is suggestive of a fracture
Inspect the vertebral spaces :
- In healthy individuals, the disc height should gradually increase from superior to inferior
- Note: the L5/S1 space is normally slightly narrower than L4/L5
- Inspect the vertebral endplates : the continuity of superior and inferior endplates should remain uninterrupted.
Trace the posterior elements including:
- Spinous processes
Ensure the vertebral and spinous processes are intact.
When describing and diagnosing spinal fractures, Radiologists divide the spinal column into 3 sections known as the ‘Three Column model’. This states that if any 2 columns are injured then the injury is ‘unstable’. If spinal instability is suspected further imaging with CT or MRI should be considered.
Involves the anterior two-thirds of the vertebral body / intervertebral disc and the anterior longitudinal ligament .
Involves the posterior aspect of the vertebral body / intervertebral disc and the posterior longitudinal ligament .
Involves the posterior elements including the lamina , facet joints , spinous processes , and the associated ligaments .
Anterior column – anterior compression fracture
An anterior compression fracture is a fracture in which the front part of the vertebral body is crushed, resulting in a wedge shape.
Anterior compression fractures are the most common type of lumbar spine fracture.
Middle column- ‘burst fracture’
A burst fracture occurs when the vertebral body is crushed in all directions simultaneously (e.g. sudden axial loading force). This type of fracture can result in bone fragments being projected outwards anteriorly into the spinal canal causing secondary spinal cord injury.
A burst fracture involves two columns and is therefore typically considered to be unstable .
Posterior column – flexion-distraction fracture
Flexion-distraction fractures (a.k.a. chance fractures) occur when any part of the spinal column breaks away from another part . This type of fracture is often caused by sudden severe compression or rotation of the spine (e.g. use of a lap-only seat belt during a deceleration injury, resulting in forceful forward flexion of the spine).
The result is a fracture of the vertebral body with associated transverse/horizontal fractures of the posterior elements . This type of fracture is unstable and carries a high risk of spinal cord injury .
Spondylosis involves degeneration of the interverbal disc leading to disc space narrowing , endplate sclerosis and osteophyte formation .
In some cases, osteophytes can cause neural impingement .
Spondylolysis occurs when a fracture (acute or chronic) extends from the inferior facet across the pars interarticularis (area of the lamina that lies within the facets), to the superior facet .
This defect can in some cases be bilateral and lead to spondylolisthesis (see below). Spondylolysis is often best identified on an oblique radiograph, appearing (with the eye of faith) to represent a “Scotty dog”: 4
- Nose: transverse process
- Eye: pedicle
- Ear: superior facet
- Front leg: inferior facet
- Neck: pars interarticularis
- Collar across the neck: fracture
Spondylolisthesis occurs when one vertebra is displaced forward upon another .
This can occur secondary to trauma or as a result of degenerative disease such as osteoarthritis. If severe it may lead to foraminal stenosis , causing nerve root impingement .
Vertebral bone lesions
Vertebral bone lesions can often be asymptomatic in patients and thus are often identified incidentally .
These lesions typically become symptomatic when they present as a pathological fracture with or without neurological deficits secondary to extension into the spinal canal.
Differential diagnoses for a lytic spinal lesion include: 6
- Prostate cancer metastases
- Breast cancer metastases
- Thyroid cancer metastases
- Renal cell carcinoma metastases
- Lung cancer metastases
- Multiple myeloma
When interpreting a lumbar spine X-ray , remember the following key points:
- Begin by confirming the patient’s details, reviewing the clinical history and ensuring the radiographs are adequate
- Compare to previous X-rays where possible to provide additional context.
- Assess alignment of the vertebral bodies and spinous processes carefully for inconsistencies indicative of underlying pathology (e.g. fracture)
- Inspect for loss of vertebral height which may be indicative of a vertebral fracture.
- Inspect the vertebral spaces : in healthy individuals, the disc height should gradually increase from superior to inferior.
- Trace the posterior elements including pedicles, laminae and spinous processes.
- Inspect for signs of fracture and determine how many columns of the ‘Three Column Model’ are affected to determine fracture stability.
- Inspect for other important pathologies such as spondylosis, spondylolysis, spondylolisthesis and vertebral body lesions.
- Projectional radiography has limitations and other imaging modalities such as MRI and CT should be considered if further evaluation is required.
Professor James Meaney
St James’s Hospital, Dublin, Ireland
- Clinical Indications for Lumbar Spine Radiographs. Available from: [ LINK ].
- St. James’s Hospital, Radiology Dept 2021
- Anatomography. Adapted by Geeky Medics. Licence: [ CC-SA-2.1 ].
- Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 20547
- Jojo. Adapted by Geeky Medics. Spondylolisthesis in the lumbar region.
- Subramanian S, Viswanathan VK. Lytic Bone Lesions. 2020 Jun 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30969659. [Accessed 9 June 2021].
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Pelvic radiograph (an approach)
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Citation, DOI, disclosures and article data
At the time the article was created Jeremy Jones had no recorded disclosures.
At the time the article was last revised Joshua Yap had no financial relationships to ineligible companies to disclose.
- Pelvis x-ray
- Pelvis xray
- Pelvic x-ray
On this page:
Systematic review, common pathology, don’t miss….
- Related articles
Cases and figures
- trace the main pelvic ring and two obturator foramina
- if a ring is disrupted, think fracture... then look for a second one
- the sacroiliac joints should be symmetrical, joint space range 2-4 mm
- the symphysis pubis joint space should be ≤5 mm
- if either joint space is widened, think main pelvic ring fracture
- iliopectineal line disruption suggests a fracture involving the anterior column
- ilioischial line disruption suggests a fracture involving the posterior column
- teardrop displacement suggests an occult acetabular fracture
- the arcuate lines should be smooth and symmetrical
- If lines angulated, think sacral fracture
- if cortical disruption, trabecular pattern disruption or transverse sclerosis, think fractured proximal femur
- If line disruption, think fractured proximal femur
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Proximal femoral fracture
- typically elderly osteoporotic females
- fall in elderly or high-energy blunt trauma
- more: proximal femoral fracture
- subcapital (most common), transcervical, or basicervical
- displaced intracapsular fractures are associated with delayed union, non-union, or avascular necrosis
- intertrochanteric (most common) or subtrochanteric
Pubic ramus fracture
- 40% of all pelvic fractures
- isolated fracture of superior or inferior ramus most common stable pelvic injury
- fall in elderly
- exercise-induced stress fractures
- more: pubic ramus fracture
Complex pelvic ring fracture
- fracture at one site often associated with a second
- a double break represents an unstable injury
- high energy blunt trauma
- requires CT evaluation
- more: complex pelvic ring fracture
- bimodal distribution: young (high energy) and elderly (poor bone quality)
- impaction of femoral head, lateral compression or axial loading
- 75% associated with femoral head subluxation/dislocation; frequently comminuted
- more: acetabular fracture
Head of femur dislocation
- 80% posterior
- associated with posterior rim acetabular fractures
- more: posterior dislocation of hip
- typically adolescent athletes
- repeated or sudden muscle contraction
- ischial tuberosity avulsion (hamstring insertion) most common
- more: ischial tuberosity avulsion
- common in pelvic ring fractures
- high-energy blunt trauma
- frequently missed
- 25% associated with neurologic injury
- more: sacral fracture
Related articles: Approach: Radiographs
- skull radiograph
- facial radiographs
- cervical spine radiograph
- thoracolumbar spine radiograph
- shoulder radiograph
- elbow radiograph
- wrist radiograph
- hand radiograph
- pelvic radiograph
- knee radiograph
- ankle radiograph
- foot radiograph
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X-Ray Report Samples (5)
Medical x-ray report samples:, x-ray report sample #1.
HANDS AND WRISTS – TWO VIEWS : Hands and wrists, two views of the right and left hand and wrist were obtained. There is generalized osteopenia. There are OA changes seen at the first CMC joint with subchondral sclerosis and joint space narrowing. Ulnar styloids appear intact. There is no chondrocalcinosis. There are some degenerative changes seen at the carpus but without any obvious erosive changes. There are no erosions seen at any of the MCP or PIP joints. There are scattered areas of joint space narrowing at the PIP and DIP joints.
IMPRESSION: 1. Osteoarthritis changes. 2. Osteopenia. 3. No definite erosions.
SHOULDERS – TWO VIEWS : Shoulders, two views of the right and left shoulder were obtained. Bony mineralization appears within normal limits. There are no lytic or blastic lesions. There is mild degenerative change at the AC joint with some joint space narrowing. A pacemaker is seen in the left hemithorax. There is minimal periarticular calcification at the left shoulder near the supraspinatus insertion. There is mild elevation in the humeral head at the left and perhaps a minimal amount on the right.
IMPRESSION: 1. Mild humeral head elevation, left greater than right, concerning for rotator cuff tendinopathy. 2. Mild OA changes at the AC joint. 3. Minimal periarticular calcification at the left shoulder with none seen on the right.
X-Ray Report Sample #2
CHEST X-RAY TWO VIEWS
REASON FOR EXAMINATION: Fever, aches and pains/flu-like symptoms.
DISCUSSION: The lungs are well aerated. There is no evidence of any focal area of consolidation. A faint rounded density is seen in the base of the left lower hemithorax probably representing a nipple shadow. The hilar and pulmonary vasculature is normal. The heart size is within normal limits. The costophrenic angles are clear.
IMPRESSION: Normal chest x-ray.
X-Ray Report Sample #3
Left foot x-ray:.
IMAGING SEQUENCES: Pre-contrast T1 weighted sagittal and axial images and post-contrast axial and coronal images.
FINDINGS: Three view of the left foot show no evidence of fracture, dislocation, or other acute bony abnormality.
NEGATIVE LEFT FOOT FILMS.
X-RAY DEPARTMENT REPORT SAMPLE #4
RIGHT SHOULDER – TWO VIEWS: Lumbosacral spine, multiple views of the lumbar spine were obtained. There appears to be a fracture at the coccyx which is age indeterminate. There is straightening of normal lumbar lordosis. Intervertebral disc spaces are maintained. Facet joints appear within normal limits bilaterally. There is a little bit of sacroiliac sclerosis bilaterally, more so on the right. The SI joints do appear patent.
IMPRESSION: 1. Suspected coccyx fracture, age indeterminate. 2. Straightening of the lumbar lordosis. 3. Sacroiliac sclerosis.
HIPS – TWO VIEWS : Hips, two views of the right and left hip were obtained. Bony mineralization is normal. There is no acute fracture seen. There is no visible enthesopathy in the limited views of the pelvis. There is a little bit of superior sclerosis at the acetabula bilaterally. The hip joint spaces appear preserved.
IMPRESSION: 1. Mild hip sclerosis. 2. Otherwise, unremarkable hips.
X-Ray Report Sample #5
X-RAYS OF THE LUMBAR SPINE:
No fractures, subluxations or other acute bony abnormalities are identified. There is mild degenerative change with mild endplate spur formation and mild facet sclerosis at all levels. No erosive or destructive changes are seen.
- MILD DEGENERATIVE CHANGES AS DESCRIBED ABOVE.
- NO DEFINITE ACUTE ABNORMALITY.
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5. Film Interpretation and Report Writing
Focus on Radiographs Common Uses of Radiographs Criteria for Ordering Radiographs Image Interpretation Report Writing Summary Sample Radiology Reports Focus on Radiographs Since its inception, diagnostic imaging has played a fundamental role in patient evaluation. Diagnostic imaging began more than 100 years previously with plain film radiography, and has progressing to advanced modalities, such as digital radiography, magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET). Diagnostic imaging remains an essential tool to recognize, define, identify, and exclude many of the common and not so common pathologies encountered in a health care setting. For most clinical assessments, the historically dominant modality of plain film radiography continues to be the first step, with more sophisticated specialized imaging systems such as MRI and CT often applied as follow-ups to negative, equivocal, or ambiguous results of the plain film study, or for clinical questions for which plain films are known to be insensitive. Plain film radiology is widely available, relatively inexpensive, and rapidly obtained, predicting it will likely remain as the most common imaging method into the near future. Plain film radiology represents a common denominator to many health professions. Dentists, podiatrists, chiropractors, medical physicians, and many practitioners in allied heath professions routinely rely on information obtained from plain film radiographs to manage their patients. With this in mind, the present chapter is focused on the interpretation and reporting of plain film radiographs. However, with little modification, the concepts presented here and targeted to plain film radiology equally relate to other more specialized imaging modalities. Therefore the goal of this chapter is to provide the reader with an understanding of issues related to when radiographs should be taken, methods to successfully search radiographs for abnormal findings, the ability to categorize these findings by appearance and location into common patterns, and steps to summarize and report on these findings successfully. Common Uses of Radiographs In 2000 an estimated $1.3 trillion was spent on personal health care in the United States. 36 Heath care expenditure was 13.1% of the gross domestic product in 2000, representing a per capita expenditure of $4377. 36 Of the most current data available, in 1990, an estimated 3.5% of these expenditures were for radiologic services, 139, 140 much of it directed to nonradiologists. Diagnostic imaging is common to clinical practice. More than 80% of chiropractors use radiographs as part of their clinical protocol and have the necessary equipment to produce radiographs in their offices. 4 Although national data are not available, a survey of Minnesota medical physicians found that approximately 87% had onsite radiology equipment. 61 Developing film interpretation skills is of obvious interest to radiologists, but developing these skills is also important to nonradiologist medical physicians, chiropractors, and other health care providers who often take and interpret radiographs as part of patient evaluation and management. For instance, most chiropractors do not regularly consult with radiologists to assist their interpretations. 63 In fact, fewer than 20% of hospitals have full-time onsite coverage by a board-certified radiologist. 101 During these off hours, the initial interpretation and related decisions are often done by nonradiologist clinicians, most to be overread by radiologists later. Moreover, of the radiologic services done in a private medical practice setting, 57% 139, 140 to 70% 90, 132 are performed and interpreted by nonradiologists. Questions arise related to the appropriateness of training of nonradiologists to interpret imaging and under what circumstance it is best to consult with a radiologist. The American College of Radiology (ACR) recommends that radiographs be interpreted by certified radiologists or physicians who have documented training in an approved residency, including radiographic training on all body areas. This indicates the basic need for formal training, but does not limit interpretations to radiologists. 5 Literature within the chiropractic profession advocates for greater use of chiropractors who are certified with advanced training in radiology (Diplomates of the American College of Radiology [DACBR]) as a method of limiting liability and enhancing accuracy of image interpretation. 51 Taylor 145 found that the degree of training positively influences the ability of medical and chiropractic clinicians and students to correctly identify selected bone and joint pathology. As one might expect, the concordance between the radiographic interpretation of radiologists and nonradiologists is best for extremity bone radiographs (approximately 95%) and lower for more complex studies, such as chest radiographs (generally ranging from 40% to 90%). * * References 19, 60, 72, 81, 83, 137 . Criteria for Ordering Radiographs The most effective application of diagnostic imaging for many common clinical presentations is widely debated. The multifaceted and unique clinical presentations of most patients make the formation of common criteria for ordering diagnostic imaging problematic at best. Everyone agrees that all radiographic examinations should follow clear historical and clinical indications because of the examination costs and potentially hazardous effect of ionizing radiation. 96 Unfortunately, there is no general agreement on exactly what these historical and clinical indications should be to satisfy the competing needs of gaining information while limiting cost and radiation exposure. To date, diverse opinions exist about what constitutes accepted clinical criteria for ordering radiographs for patients with musculoskeletal complaints. Although the literature documents many attempts to develop criteria for ordering radiographs for patients with complaints of the spine, † no system has been generally accepted. As a matter of observation, the use rates of plain film radiographs vary widely. Developing and embedding guidelines seem easier tasks for a narrow-scope presentation of something such as ankle 112, 134 or knee trauma, 135, 136 but are less successful for case presentations of increasing complexity and ambiguity (e.g., back pain) and applied management (e.g., pharmaceuticals versus manual adjustments or manipulation of the spine). † References 1 , 41 , 42 , 44 , 46 , 98 , 111 , 119 , 127 , 133 , 149 . Opinions vary widely about the use of radiographs in the evaluation of patients experiencing back pain. Multiple questions cloud the issue. Should radiographs be taken of patients who are experiencing acute but not chronic back pain? What are the appropriate film-ordering criteria that maximize clinical information yet minimize patient cost and radiation exposure? Despite the fact that these topics have garnered considerable attention over the past decade, evidence-based guidelines for the use of plain film radiology (or CT and MRI) are not widely used in the clinical setting. 52 In 1987 the Quebec Task Force, and later the United States’ Agency for Health Care Policy and Research (AHCPR), developed guidelines for the use of plain film imaging related to patient presentation of acute low back pain. Similar efforts occurred in other countries. 27, 36, 122 The premise is that guidelines effectively influence practitioners’ use of plain films, as has been shown to occur in some instances. 42, 78 However, guidelines prove less effective as the population and clinical problems become less homogeneous and more complex. Factors affecting whether radiographs are taken include clinical data, patient expectations, and clinicians’ attempts to reassure patients or themselves. 91, 104, 157 Also the type of practitioner is very important: The use of radiographs for low back complaints varies from 2% to 48%, depending on the type of practitioner. 52 Chiropractors—who employ a manual approach to patient care—and orthopedic specialists demonstrate increased use of plain film radiographs compared with medical physicians in family practice who manage patients with acute low back pain. 32 This observation may result in part from a bias toward searching for a musculoskeletal derangement as the cause of the patient’s complaint; however, it probably also reflects varying therapeutic approaches to patients’ complaints and the need for structural information related to the delivery of care and patient management. In chiropractic practice, radiographs generally are considered a standard first-step imaging protocol when evaluating degenerative and inflammatory joint disease, fractures, infections, and neoplasms. 57 The hands-on management approach of chiropractors warrants attention to biomechanical influences and potential structural contraindications to intended interventions ( Fig. 5-1 ). Nonchiropractic clinicians, whose management of low back pain centers on exercise, patient education, pharmaceuticals, and other clinician-passive therapies, have less use for the biomechanical or structural information obtained from radiographs. Therefore these practitioners can easily adopt a more conservative approach to taking radiographs for musculoskeletal spine complaints than can chiropractors or other practitioners, who apply manual intervention. FIG. 5-1 Three streams of information from the radiograph. In the context of delivering chiropractic care (or other manual approaches to patient care), radiographs provide three types of information: (a) information related to possible structural contraindications or cautions to delivering a corrective force into the demonstrated anatomy; (b) information that may influence the direction or technical approach to delivering a corrective force; and (c) information related to diseases, conditions, or findings that are seen in addition to the chiropractic subluxation, osteopathic lesion, or primary reasons the radiographs were taken. For instance, this radiograph demonstrates osteopenia that will influence the delivery of the chiropractic adjustment (stream A). There may be biomechanical or degenerative features that will cause the chiropractor to adjust one segment over another, thereby influencing the technical approach to the patient (stream B). Last, the compression fractures may result from an underlying aggressive pathology such as metastasis that would be of great concern to the clinician, beyond the issue related to the chiropractic subluxation or the initial concerns of the clinician (stream C) . Many radiographs taken in a chiropractic setting are interpreted as normal for serious bone pathology, 82 but they may relate biomechanical or structural information that allows the chiropractor to be more successful with technical aspects of formulating and applying the patient’s management plan. However, more research into the reliability, validity, and clinical usefulness of biomechanical and structural information gleaned from radiographs is necessary. Also evidence is needed to clearly justify the added costs, define criteria of patient selection, and facilitate advancements in care delivery. All clinicians, regardless of therapeutic approach, are concerned with serious pathology masking as routine low back pain. Clinical red flags that suggest the presence of serious pathology have been developed and are helpful to direct patient selection ( Box 5-1 ). In the absence of these red flags, significant spinal pathology is estimated in only 1 of 2500 patients. 152 Deyo and Diehl 43 evaluated 1975 walk-in patients at a public hospital to estimate the prevalence of cancer as an underlying cause of the patient’s back pain. Using a developed algorithm that generally reflects the questions listed in Box 5-1 , only 22% of these patients would have received x-rays; this proportion includes all those who were later found to have cancer. BOX 5-1 Clinical Red Flags of Serious Spinal Pathology (e.g., Infection, Tumor, or Fracture) Unexplained weight loss Personal history of cancer Unexplained fever Age more than 50 years Intravenous drug use Prolonged corticosteroid use Severe, unremitting pain at night Trauma sufficient to cause fracture or injury Pain that worsens when the patient is lying down Features of cauda equina syndrome Urinary retention Bilateral neurologic signs or symptoms Saddle anesthesia From Deyo RA, Diehl AK: Lumbar spine films in primary care: current use and effects of selective ordering criteria, J Gen Intern Med 1:20, 1986. It should not be assumed that instituting guidelines, such as those listed in Box 5-1 , will lead to less use. For example, Canadian researchers found that if the guidelines listed in Box 5-1 had been applied to their study population of 963 patients in a private medical family practice setting, 44% would have undergone radiography, increasing actual use by 238%. Considering patient follow-up, these researchers concluded that the sensitivity of the guidelines to detect fractures and tumors was higher than the physicians’ use patterns, but their specificity and positive predictive values were low. 138 Parallel and similarly controversial issues surround the application of specialized imaging. (e.g., whether MRI should be ordered for a patient in whom a disc herniation is clinically suspected yet neurologic findings are limited). This is especially true when the literature suggests that approximately 25% of normal adults demonstrate acquired spinal stenosis and 33% have a disc herniation, 44 two key MRI findings. In the absence of clear guidelines, clinicians must adhere to a logical rule for the use of all diagnostic procedures: If the patient’s diagnosis or management is likely to significantly change from information routinely provided by the diagnostic procedure in question, then the study should be performed; if the necessary information is not routinely provided by the procedure or knowing the information obtained will not change the patient’s management, then the procedure should not be performed. Image Interpretation EQUIPMENT AND RESOURCES Before the skills and knowledge of the interpreter can be brought to task, the images should be clearly displayed and reference material should be close at hand. This is a digital age, but clearly the revolution has not permeated all segments of the population evenly. Although many clinics have moved to filmless methods for acquiring and displaying images, not all are so advanced. Much radiology, particularly plain film, is still accomplished traditionally; this produces radiographs that should be viewed on illuminated light boxes. These view boxes generally are available in two sizes, the standard 14 × 17 inch view box, and a larger 14 × 36 inch view box that accommodates a full spine radiograph, the type often used to assess scoliosis. Standard 14 × 17 inch view boxes are combined in various configurations to create a viewing station ( Fig. 5-2 ). FIG. 5-2 View box station. View boxes are arranged in various formats to construct a viewing station. This picture exhibits a simple four over four bank on the right and a two over two bank to the left of it. High-volume centers may invest in a viewing system with rotating panels or belts that pass the films in front of a stationary bank of lights, because placing the films on and off the view box can consume a considerable amount of time. This system allows many cases to be stored and viewed quickly, without the need to shuffle through the films of each case as they are put on and off the view box. A “hot” or “bright” light is another important tool necessary for film interpretation ( Fig. 5-3 ). The hot light produces a controllable high-intensity beam of light that helps the interpreter view the overexposed (dark or radiolucent) areas of the film. The intensity of the light can be controlled with a pedal that allows the interpreter to match the brightness of the light to the darkness of the radiograph. Even radiographs that are executed under the highest technical standard have regions of overexposed anatomy. Some of the more common and significant pathologies often hide in the overexposed areas of the film, making it difficult to recognize them when viewing the films only on a view box. Therefore a hot light is an essential tool to a thorough film interpretation. FIG. 5-3 Hot light. The hot light (also known as a bright light ) is an essential tool to film interpretation. By using a hot light, the interpreter is able to view the overexposed regions of the film. Some of the most serious pathologies (e.g., lung nodules, aneurysms) are common to the overexposed regions of a radiograph and are more easily seen with the aid of a hot light. It has been said that “a radiologist with a ruler is a radiologist in trouble.” 97 Although the sentiment underscores the importance of clinical intuition, observation, and training, the reality is that handy access to rulers, protractors, or other measuring devices allows more accurate quantification of structural abnormalities. For instance, the degree of spondylolisthesis is related to the likelihood of its further progression, the rate of growth of a pulmonary nodule is predictive of its malignant potential, the degree of scoliosis is central to the management of the case, and so on. Reference texts should be close at hand. The usefulness of some radiology books transcend the typical, such as Keats’ Atlas of Normal Roentgen Variants That May Simulate Disease. 76 A recent edition of Keats’ atlas should be close to the reading area. As the title describes, this book is a regional atlas of abnormal film findings that are normal variants of anatomy. This book is comprehensive and includes both subtle and grossly abnormal cases. Recognizing that an abnormal finding is a normal variant saves time and examination costs related to erroneous additional evaluation. For example, view the case exhibited in Figure 5-4 of a 12-year-old with a history of trauma. The calcaneus clearly looks fractured, but the radiolucent defect actually represents an unfused secondary growth at the center of the calcaneal tuberosity. A similar case is noted in the third edition of Keats’ book. 76 Recognizing that this is a normal variant and not a fracture ensures that time and expense are not wasted. FIG. 5-4 Lateral ankle of a 12-year-old who recently suffered a trauma to the calcaneus. The radiolucent line appearing as a fracture (arrow) actually represents a normal appearance of the secondary growth centers. This case demonstrates how closely some normal findings and variants of normal may simulate a disease state. (Courtesy C. Robert Tatum, Davenport, IA.) ERRORS IN FILM INTERPRETATION Interpreter error may arise from a failure to see, recognize, or understand the significance of a lesion. Although errors rates of 20% to 30% have been reported, 55 the more contemporary literature indicates that approximately 1% to 3% of plain film interpretations done by nonradiologists contain important errors. * Most of these studies are done by emergency department personnel. * References 30 , 50 , 58 , 79 , 113 , 118 , 148 , 153 , 155 . Seltzer 128 estimates that 8% of interpretations by medical radiology residents contain potentially clinically important errors, which suggests that misinterpretation is increased in interpreters with fewer qualifications. Complex studies (e.g., CT) 2 and studies on pediatric patients 129 also increase misinterpretation. Fractures are the most often-missed lesions. 30, 118, 155 Training is associated with more accurate interpretation, 145 but radiologists are not immune to misinterpretations, as studied with various methods and imaging modalities. 65 66 67 68 69 93 and 116 Most studies focus on false-negative readings; however, false-positive readings occur among radiologists 30 and nonradiologists 153 alike. False-positives promote continued patient evaluation, adding to the cost, which is estimated to average $85 per false-positive reading. 153 Unnecessary examinations also result in increased risk of complications associated with imaging. Alleged diagnostic errors account for the majority of legal cases related to radiology departments. 20 However, not every missed lesion constitutes evidence of negligence. Statistics pointing to related rates of missed lesions, limitations of normal human visual perception, image quality, and many other factors influence image interpretation, and may be mitigating factors for image misinterpretation. 20 21 22 23 24 and 130 The conceptual difference between errors in interpretation and those arising from perceptual variations is well described by Robinson. 117 The former assumes the diagnosis is known and generally agreed upon as a lesion; the latter does not ( Fig. 5-5 ). FIG. 5-5 Errors in image interpretation. This figure depicts a relationship between the imaging appearance of a lesion (size, shape, etc.) and the probability that the apparent lesion truly is one. (A) At times, their may be an uncertain or mixed interpretation of a grossly abnormal feature (e.g., importance of a lumbosacral transitional segmentation or spondylolisthesis). (B) Easy cases to interpret are defined as those that appear clearly abnormal on imaging and have a high degree of certainty that they are real lesions. Misinterpreting such a case is a clear error. (C) In contrast, difficult cases are those that present with only mild departures from the appearance of normal anatomy and are associated with doubtful conclusions on whether a true lesion is present. Misinterpreting this case may reflect a genuine difference of opinion among experts, representing variation in opinion more than direct error. (D) Last, only a small deviation from normal anatomy may correlates to a certain lesion. For example, a small corner fracture of the phalanx appears subtle, but has a certain interpretation as a lesion. The watershed of acceptable performance represents the line between clear-cut error and the inevitable difference in opinion existing between and among professionals. (From Robinson PJ: Radiology’s Achilles’ heel: error and variation in the interpretation of the Roentgen image, Br J Radiol 70:1085, 1997.) The goal of film interpretation is to eliminate as many misinterpretations as possible. There is a substantial literature addressing the topic of radiologic interpretation (see Table 5-1 ). The literature and conventional wisdom indicate that although it is impossible to eliminate human error, and therefore mistakes of radiologic interpretation, then attention to common principles should prove beneficial ( Box 5-2 ). TABLE 5-1 Annotated Bibliography of Selected Articles Addressing Radiologic Image Interpretation Topic Article Summary Ambient light Alter AJ et al 3 Employing low ambient room light, illuminating only films being viewed, and masking the radiograph around areas of interest improves visual performance; however, is cumbersome to implement completely in a clinical setting. Appearance of the lesion Krupinski EA et al 85 This study found that physical features of pulmonary nodules do not attract attention as measured by “first hit” fixation of the interpreter’s gaze; however, certain features do tend to hold the attention once the nodule has been fixated. The combination of all features influences whether or not it is detected. Experience Herman PG et al 66 After having several interpreters view a series of chest radiographs, the authors found that, “Once an individual’s radiology education has progressed beyond a fundamental level, individual reader characteristics overshadow experience (and training) in the accuracy of chest film interpretation.” Experience Nodine CF et al 100 Differences in resident performance resulted primarily from lack of perceptual-learning experience during mammography training, which limited object recognition skills and made it difficult to determine differences between malignant lesions, benign lesions, and normal image perturbations. A proposed solution is systematic mentor-guided training that links image perception to feedback about the reasons underlying decision making. Experience Qu G, Huda W, Belden CJ 114 Trained observers are superior to untrained observers when assessing characteristics of phantom images. Experience Krupinski EA, Weinstein RS, Rozek LS 86 There is a positive correlation between years of clinical experience and ability to successfully interpret radiographic images. Experience Nodine CF, Krupinski EA 99 Performance on two visual search and detection tasks indicate that radiologists do not possess superior visual skills compared with lay people. Radiology expertise is more likely to be a combination of specific visual and cognitive skills derived from medical training and experience in detecting and determining the diagnostic importance of radiographic findings. Experience Rhea JT, Potsaid MS, DeLuca SA 116 Experienced interpreters exhibited lower rates of false-positive and false-negative readings. Experience Sowden PT, Rose D, Davies IR 131 Performance of a wide range of simple visual tasks improves with practice. This learning may be a specific function of the eye. Experience Taylor JAM et al 145 This study demonstrated a significant association between the interpreters (both medical and chiropractic) training and their ability to recognize abnormal radiographs of the lumbosacral spine and pelvis. Eye dwell time and axis of gaze Carmody DP, Nodine CF, Kundel HL 34 “Our findings indicate that a dwell time of 300 ms was sufficient to detect 85% of the nodules when they were viewed directly. Detection accuracy was reduced by one-half when the tumor was located 5 degrees from the axis of gaze.” Eye gaze durations, scan paths, and detection times Krupinski EA 84 Readers with more experience tended to detect lesions earlier in the search than did readers with less experience, but those with less experience tended to spend more time overall searching the images and cover more image area than did those with more experience. Confidence level Mayhue FE et al 94 Prospective interpretations of nearly 1900 emergency room radiographs were performed by multiple interpreters. The concordance of agreement varied by level of confidence, but not training level among the interpreters. Influence of patient history Berbaum KS et al 15 This study tested whether accompanying patient clinical information would improve perception or simply decision making. The report found that the interpreter’s detection of pathology was significantly better with history provided before film inspection. Detection did not differ for history provided after inspection and inspection without history. The authors concluded, “clinical history affected perception in interpreting radiographs, not simply decision making.” Influence of patient history Berbaum KS, Franken EA, el-Khoury GY 17 A brief patient history may provide localization clues that improve the ability of interpreters to detect fractures and other features of trauma. When localization clues are withheld or unavailable, radiologists and nonradiologists alike are less successful in finding trauma lesions; although the accuracy of the radiologists suffers less. Influence of patient history Good BC et al 56 Researchers found that knowledge of clinical history does not affect the accuracy of radiologists’interpretations of chest films for the detection of pathologies such as interstitial disease, nodules, and pneumothoraces. Miss rates Robinson PJ 117 This is a literature review of strategies for reducing error in radiograph interpretation. Methods include: attention to viewing conditions, training of observers, availability of previous films and relevant clinical data, dual or multiple reporting, standardization of terminology and report format, and assistance from computers. Miss rates Herman PG et al 65 These authors found that 41% of chest radiograph reports contained potentially significant errors and 56% showed indeterminate disagreement. In addition, 78% of all errors were false-negatives and 22% were false-positives. Perception of the image Kundel HL, Nodine CF 89 These authors advocate that image perception begins with characterization of the scene integrating data from the retina and memory to form a visual concept. This theory holds that it may be necessary to have seen radiologic abnormalities in the past to be able to form an appropriate visual concept for a current abnormality. Prior studies Berbaum KS, Smith WL 18 “Old reports add value to current interpretation by providing a form of ‘second reading’ and providing clinical history. Two years is sufficient old report access in 85% of situations.” Satisfaction of search errors Berbaum KS et al 16 This defines the satisfaction of search phenomenon in diagnostic radiology and the development of statistical methods to measure observer performance. Satisfaction of search errors Ashman CJ, Yu JS, Wolfman D 7 The satisfaction of search phenomena describes a situation in which the detection of one radiographic abnormality interferes with the detection of others. Satisfaction of search defects of film interpretation is operative in the interpretation of radiographs of the musculoskeletal system. Satisfaction of search errors Berbaum KS et al 14 It appears that satisfaction of search errors originate from recognition failures more than poor decision making. Satisfaction of search errors Berbaum KS et al 13 An appropriate history appears to reduce satisfaction of search errors. It is believed that detailed histories direct the interpreter’s perceptual resources to the prompted abnormalities, reducing the satisfaction of search error. Search path Kundel HL, Nodine CF 88 This experiment quickly flashed the image as a means of negating the ability for observers to visually scan the image, resulting in an overall true-positive rate of 70%. As anticipated, the rate improved to 97% with the addition of a free search of the images. These data support the fact that visual search begins with a global response of the interpreter to the image to establish content and detect gross deviations from normal. Search path Beard DV et al 10 Radiologists’film interpretation has a typical sequence. Films are mounted in order; radiologists generally start a sequential scan through the entire examination; this is followed by a detailed viewing of two to four clusters of three to six images; and last the findings are dictated or otherwise recorded. Search path Hu CH et al 74 More systematic scanning patterns were observed for experienced than inexperienced observers. Search path Carmody DP, Kundel HL, Toto LC 33 Although radiologists are formally trained to search radiographs using a systematic and directive search path with comparison of bilateral features, only 4% of visual activity was accomplished with bilateral comparison when observed. Most radiologists used a flexible search path. Search path Swensson RG, Hessel SJ, Herman PG 143 Data collected on readings of chest radiographs found that “radiologists could distinguish between normal and abnormal radiographs better when searching the chest films for any abnormal findings than when explicitly evaluating” the radiographs for specific features to which their attention is directed. The authors theorize that “the recognition of abnormal findings may have been augmented by perceptual mechanisms that functioned only during the process of visual search.” Search path Peterson C 107 The authors found that chiropractic students who employed a flexible but complete search pattern when interpreting radiographs performed significantly better than their peers using any other search pattern approach. Second opinions Swensson RG, Theodore GH 142 This study involved multiple interpretations of chest radiographs and found that second opinions are more accurate if the second interpreter is not aware of the concerns or findings of the first interpreter. BOX 5-2 Suggestions to Reduce Radiologic Interpretation Errors 1. Become familiar with the patient data . The age, gender, and ethnicity of the patient may offer potent predictors of what disease process is represented on the radiographs. For instance, a 2-cm solitary radiodense defect of the L4 vertebral body is likely a bone island in a patient under 30 years of age. By contrast, a metastatic deposit needs to be excluded in a patient more than 40 years of age. Patient demographics directly influence clinical decision making. 2. Become familiar with the clinical context of the study . The clinical rationale for the study should be known before a patient’s images are viewed. The interpreter should have a good idea of what he or she will encounter before the films come out of the processor. For example, are the films done to evaluate the patient for a clinically suspected rib fracture? Knowing the clinical context is essential to a thorough interpretation. 3. Assess technical factors, image quality, and artifacts . The images should be of sufficient quality and the correct area of clinical interest. Film interpretation is directly and negatively influenced by poor technical factors, such as improper patient positioning, patient motion, and many others problems that are more fully discussed in Chapter 1 . Faint shadows of pathology may not be visible if the images are underexposed or overexposed. Patient motion is probably the most common technical defect that degrades image interpretation. Also, all of the clinically relevant anatomy must be visible to the degree expected. Images taken when the patient is recumbent may cause some of the anatomy to appear quite different. A case in point is the difference in size of the heart shadow on recumbent and upright films, or inspiration versus expiration patient instructions on upright films. Clothing and other artifacts can form ambiguous presentations on radiographs. 4. Search the images using an intentional, thorough visual path . Image interpretation has a greater chance of being successful if steps are taken to view the entire image in a complete manner. One popular approach to film interpretation involves a review of the alignments (A) of structures, bone (B) elements, cartilage (C) or joint spaces, and soft tissues (S). This is known as the “ABCS” approach to film interpretation and the method ensures that all of the anatomy is viewed completely. However, the interpreter should not be a slave to the ABCS sequence of film interpretation. For some, the ABCS approach may be more naturally applied as a BCAS or CABS sequence. The important point is that all of the anatomy is viewed; the order is less critical. When an abnormal finding is discovered, a free search path is invoked to follow the features of the disease. Once all of the related findings have been observed, the interpreter returns to a fixed sequence to ensure that all of the anatomy has been viewed. The search path never should be haphazard. It needs to intentionally follow the predetermined path of the anatomy (e.g., alignments, bone, cartilage, soft tissue) or trail of pathologic findings (e.g., observed fracture line, associated angulation, soft-tissue distension). 5. Patients are entitled to more than one problem . As mentioned, the radiographs should be searched completely for defects in the alignment, bones, cartilage joint spaces, and soft tissues. It is especially important to be vigilant to a complete search pattern after a lesion is uncovered. For instance, at times the interpreter may become so preoccupied with the first abnormality detected that a second or third lesion may be overlooked. This is a well-established phenomenon known as a “satisfaction of search error.” 7, 16 By definition, satisfaction of search errors represent omissions of underreading images. The satisfaction of search phenomenon is more likely to manifest when the first lesion is generally more attention-grabbing than the subsequent, more subtle lesion. 124 Although the causes of satisfaction of search errors are not explicitly defined, these errors may be reduced if interpreters are aware of the tendency to miss subsequent lesions, and hopefully develop a tendency to closely look for a second lesion whenever a first lesion is found, a third when a second is found, and so on until the anatomy is viewed completely. A complete search pattern is the only defense to avoid this well-known pitfall of image interpretation. 6. Compare what is seen with the “mind’s eye of normal.” After a review of the patient’s demographics, the rationale for examination, and technical issues related to the image, image interpretation next begins with a thorough search of the displayed anatomy for any deviations from normal. This step is the most crucial of the film interpretation process. Image interpretation requires an excellent knowledge of normal anatomy. Abnormality quickly catches the eye when normal is understood. 87 7. Common things are commonly seen (or, rare things are rarely seen) . This concept underscores the importance of trying to explain the cause of abnormal findings by starting with the common pathologies and working to the less common differentials. For instance, a fragmented, radiodense, small proximal epiphysis appearing on hip radiographs of a 6-year-old boy could signify hypothyroidism, but there is a better chance that it represents traumatically induced avascular necrosis. 8. Be proactive, not reactive . Excluding common pathologic presentations should be proactively attempted; that is, pathologies that are common to some radiographs should be routinely investigated. For example, when an anteroposterior (AP) open-mouth projection is viewed, an odontoid fracture should specifically be looked for. Signs of an aneurysm of the abdominal aorta on a lateral lumbar projection, a femoral neck fracture on an AP view of the pelvis, and so on should be checked. Features of the pathology should not simply be reacted to; common pathologic presentations should be proactively eliminated, especially those suggested clinically. 9. There is no substitute for experience . Critically interpreting large numbers of radiographs will help interpreters develop a strong sense of normal anatomy, and allow subtle abnormal shadows to be more apparent. 10. Consult with someone on difficult or ambiguous cases . The social literature says that two minds are better than one. A group decision generally is more accurate than an individual conclusion. Keeping with this theme, when ambiguous findings are recognized or intuitively suspected, it may be helpful to obtain a second opinion to resolve any controversy and arrive at a valid film interpretation. Interestingly, research suggests that when asking another interpreter to view the film, it is better to blind the second interpreter to the suspicious areas of the film found by the first examiner. Swenson and Theodore 142 found that second interpreters of chest films were more accurate if they read the films using a “free search pattern,” unencumbered and independent of the exact prior concerns of the first interpreter. The theory that supports this assertion is described as “superiority of search.” The theory holds that when interpreters review standard radiographic views (e.g., posteroanterior (PA) chest film), they go through a process of skilled perceptual filtering that allows them to recognize abnormal findings. Diagnostic radiology is a visual interpretation reliant on knowledge and visual acuity. It is dependent on the ability to sort information to arrive at clinically meaningful conclusions. Moreover, if the search pattern used by the radiologist is interrupted (in this case, by being tipped off to what to look at), the perceptual mechanisms are bypassed, resulting in a less accurate interpretation. 142 There is empiric evidence that second opinions are helpful to the interpretation of chest radiographs, 67, 159 barium enemas, 103 and mammography. 6, 25, 29 11. Search for links between findings and various views . Cognitively linking related findings together should be attempted in hopes of developing a perceptional flow to the image interpretation. Triangulation between the available views of the region (e.g., PA and lateral chest or AP, AP open-mouth, lateral cervical spine) should be used. Some interpreters embrace the concept that related anatomy should be reviewed together. For instance, when viewing a PA chest film it makes more sense to view all of the ribs separate from viewing the pulmonary tissues, as opposed to viewing the first rib and estimated pulmonary tissues concurrently. 12. Eliminate extraneous light . The ambient room light should be low, and view boxes that are not displaying images should be turned off. 13. Compare current findings with those on past radiographs . Past imaging studies are very useful to aid in the interpretation of current radiographs. 12, 156 Berbaum found that normal comparison images were especially helpful for those interpreters who were in the earlier stage of training. 12 This is believed to be related to the perceptual operation in which single perceptions from the old and new film combine to form a common, third, unique perception. Comparison with past radiographs also helps to document the progression of a lesion. The stability of a lesion over time is a key predictor of its aggressiveness. For example, a 1-cm lung nodule not seen on radiographs 6 months previously likely indicates a malignant etiology of the nodule. If the nodule was on an early film and of consistent size on the past images, an etiology of granulomatous infection is likely to explain the nodule. However, caution is necessary. At times the progression of a pathology may be so subtle as to be missed when very recent past radiographs are viewed. Use of multiple comparisons, including old past images, is best to avoid this pitfall. 14. The problem is perception . Image interpretation is a function of perception more than visual acuity. The question is not what can be seen, but identifying what is seen. Interpreters tend to overlay personal bias onto the process of image interpretation. It takes discipline to focus on the objective interpretation of the demonstrated anatomy. Perception is made better by experience and continually correlating what is seen to what is actually present. This is learned best by iterations of comparing one’s interpretation with that of someone more proficient. 15. Is the abnormal finding real? When abnormal shadows are seen on the image, it should first be considered that they may represent nothing more than a presentation of normal anatomy, artifact, or confluence of overlying shadows. It is common for superimposed structures to form a resultant shape. For instance, the pulmonary arteries coursing in multiple directions across the lung may combine to give the appearance of a circular, cystic pulmonary defect. The resulting “virtual image” is termed a subjective image. It is not real; rather, it is an illusion conjured in the mind of the interpreter. 16. Give special attention to the problem areas of the radiograph . Some areas on the film are more likely to contain pathology than others. For instance, attention must be paid to interpret the lung apices on the AP lower cervical radiograph; the atlantodental interval and sella turcica are important areas that are often neglected on the lateral radiograph. Problem areas for various projections are listed in FIG. 5-12 FIG. 5-13 FIG. 5-14 FIG. 5-15 FIG. 5-16 FIG. 5-17 FIG. 5-18 FIG. 5-19 and FIG. 5-20 . Generally, special attention should be given to the overexposed, radiolucent areas of all projections as common sites for pathology. 17. Be organized . Successful film interpretation requires some attention to detail. The patient’s images should be accompanied by a correlating history and pertinent clinical data, inclusive of any past imaging studies that may assist the interpretation. Resources (e.g., books, rulers, protractors, voice recorders, alcohol to erase pencil lines, dry erase markers for annotating abnormal findings) should be close at hand. Part of being organized involves consistency in how the images are assembled on the view boxes. For instance, many interpreters feel compelled to place the lateral radiographs on the view box so the patients are facing to the interpreter’s reading left, or view the films in a consistent sequence: lateral … AP … oblique, etc. 18. Attention to environment . The film reading environment should be quiet and free of distractions. Maintaining low ambient room light and turning off view boxes without films are both empirically associated with successful image interpretation. 19. What is the clinical impact? The purpose of diagnostic imaging is to gather data to assist clinical decision making. Therefore all abnormal findings should be interpreted in light of their clinical significance with appropriate follow-up imaging or procedures formulated into the report generated from the images. 20. Do not ignore intuition . The largest portion of the variation in film interpretation is unexplained. Sometimes the only predictor of an abnormality is that lingering sense that something is being missed. This feeling often drives extra attention that may eventually reveal a subtle defect. Perhaps the eyes are seeing something that the brain cannot immediately comprehend. 21. Resist overinterpreting the study . No matter how closely they are scrutinized, plain film radiographs do not reliably detail a disc lesion, ependymoma, hydrosyringomyelia, or a host of other defects. The clinical utility of the imaging modality must always be matched to the clinical question, and the modality’s limitations must be considered. The temptation must be resisted to assume that the patient’s problem is illustrated on the imaging study being reviewed. Also, a link must not be assumed between the patient’s clinical problem and radiographic abnormalities that happen to be present. The early literature is replete with assumptive correlations that could not be supported when investigated in greater depth. 22. Confirm findings with other views or studies . If findings are equivocal, further views, contrast, specialized imaging, and so on should be used to increase the certainty about something found. For example, after careful review of the anteroposterior (AP) and lateral projections of the 56-year-old woman shown in Figure 5-6 , it is apparent that the x-ray quality could be better. The patient is a large woman, and the typical problems of this circumstance are exhibited on these radiographs, such as the general “gray” appearance of the images related to excessive beam scatter. The anatomy of the lateral projection appears more radiodense in the lower portion of the lumbar spine and sacrum because the patient is wider at her hips than waist. Also, the overlying osseous shadows of the ilia add radiodensity. A skin fold creates a radiolucent transverse band at the level of the L3 disc space on the lateral projection. A degenerative spondylolisthesis is noted at L4 on L5. Multiple metallic clips are noted incidentally on the anteroposterior (AP) projection positioned along the periphery of the pelvis. The clips are related to a surgical procedure the patient underwent months earlier to remove a uterine carcinoma. Unfortunately, the surgical removal was not curative, and pulmonary metastasis is evidenced by the large mass appearing immediately superior to the apex of the diaphragm adjacent to the gastric air bubble, as seen on the lateral projection ( Fig. 5-6, A ). The presentation of the lung mass at the periphery of the film could cause it to be missed during initial review of the radiograph. Lesions appearing on the periphery of the film are not as evident as those appearing in the center. Remembering to give equal attention to the periphery of the image and adhering to the other principles of film interpretation (many listed in Box 5-2 ) reduces the rate of missed lesions. FIG. 5-6 A, Lateral and, B, anteroposterior projection of the lumbopelvic skeleton (see text for description of the findings). Perceptual variations are more likely to occur when the lesion is subtle and its clinical interpretation is unknown or undecided. There are also limitations in the visual process. Two such limitations (ambiguous images and Mach bands) are discussed in the following. Ambiguous image. When it comes to plain film radiography, our visual systems are constrained by interpreting two-dimensional representations of three-dimensional anatomy. The mental image formed may represent assumptions made of the depth of every point in the image. These assumptions may change over time, yielding dramatically different anatomic interpretations. This phenomenon can be self-demonstrated by viewing ambiguous images ( Figs. 5-7 and 5-8 ). Ambiguous images cause perceptional vacillation, although the optical input remains constant. Fluctuations in perception are thought to reflect ambiguous information about the nature of an object at a given location in visual space. The brain reacts to uncertainty by fluctuating between different neural states over time. 8, 80 Ambiguous images and other pitfalls of image perception and interpretation are possible. Generally, the film interpreter is cautioned not to assume that perception is reality. FIG. 5-7 Ambiguous image. An ambiguous image has the potential for more than one interpretation. For example, notice that the white cup can also be interpreted as the profile of two dark gray opposing faces. FIG. 5-8 Ambiguous image. A classical ambiguous image was developed by E.G. Boring, and inspired by earlier renditions of the image that appeared on postcards and advertisements. The image depicts a young woman from the perspective of looking over her left shoulder as she wears a large boa and hat with a posteriorly directed feather. If you look at the image long enough, instead of a young woman, you will see an old woman from her left anterior perspective. The jaw line of the young woman becomes the lower margin of the nose of the old woman, the young woman’s ear becomes the old woman’s left eye, and the young woman’s necklace becomes the old woman’s month, partially open. Ambiguous images arise from difficulties in interpreting three-dimensional structures from two dimensional imaging modalities. The film interpreter is cautioned to consider the impact of ambiguous images on their perceptions during image interpretation. (From Boring EG: A new ambiguous figure, Amer J Psychol 42: 444, 1930.) Mach bands. A Mach band illusion is another common source of radiographic misinterpretation ( Fig. 5-9 ). The human visual system may accentuate an abrupt change in brightness of an image so that regions of constant brightness appear to have varying brightness. This appearance is an illusion caused by the brain trying to enhance the contrast between slightly different hues of color (or gray scale). For example, in an AP open-mouth projection of the upper cervical spine, there may appear to be a transverse fracture of the odontoid process immediately adjacent to the overlapping anterior arch of the atlas. This illusion is caused by a perceived change in the radiodensity of the odontoid process ( Fig. 5-10 ). A band of perceived (but not real) contrast enhancement is termed a Mach band . 49 A Mach band appears as a thin bright band on the lighter side and a thin dark band on the darker side of the gray scale, or color, gradient. Verification of a Mach band can be performed by a densitometer; the meter will not fluctuate across the perceived contrast enhancement. FIG. 5-9 Mach bands. The human visual system may accentuate an abrupt change in brightness of an image so that selected regions of constant brightness appear to have varying brightness. A, For example, the gradient above has three even steps, but there is a perception of a brighter strip immediately before each gradient change and darker strip immediately after the gradient change. This phenomenon can be graphically represented by the solid black line indicating the three steps in brightness that occur between each of the four shades of gray scale. The human visual system will accentuate the actual (black line) change in brightness to give the illusion of darker stripes parallel to and just before the gradient change and brighter line running parallel to and immediately after the gradient change. This perceived gradient change is depicted by the dashed blue line. B, Another example is this circular gradient change. Notice how there appears to be a white halo around the black ( center ) to white ( periphery ) gradient. In this example, the white halo is a mach band. FIG. 5-10 Mach bands across the odontoid process. A, Notice the radiolucent line across the base of the odontoid process ( arrows ). The radiolucent line is not real, but rather is caused by the overlapping posterior arch of the atlas above. The overlapping posterior arch changes the density gradient of the image and promotes the interpretation of a radiolucent line adjacent to the radiodense shadow. The odontoid is not really fractured. B, The overlapping inferior margin of the skull causes the appearance of a separated tip of the odontoid process ( arrows ). As in A, the odontoid is not really fractured. At times, it is difficult to separate a Mach band from a true fracture. When in doubt, the projection could be retaken with a slightly different head tilt. On the repeat radiograph, the Mach band should move; the fracture will not. APPEARANCE OF THE RADIOGRAPH A typical family photograph is a positive image. Everything that is white appears white; everything that is black appears black; and so on. A radiograph is a negative image. In reference to subject density, dense structures (a function of mass and volume), such as metal and bone, appear whiter than do less dense structures, such as fat or water. In this sense, the radiograph is a shadow of anatomy. Dense structures impede more of the x-ray beam from striking the radiographic film; therefore after chemical development, the area appears white (or light gray) when the radiograph is back-lighted on a view box. Less dense anatomy appears dark gray or black on the film. The term radiopaque describes dense structures that block most of the x-ray beam and consequently appear white on the radiograph. The term radiolucent describes less dense structures that block little of the x-ray beam and consequently appear dark gray or black on the radiograph. In distinction to subject density, film density describes the film’s ability to stop light passing through the film. The final appearance of the radiograph is a function of the summation of many superimposed structures. It may be that several superimposed structures of medium to low density appear on the radiograph as a lighter gray shadow than a single dense object. An x-ray beam that traverses a thin bone may appear more radiolucent (sometimes termed less dense) than when the same x-ray beam traverses a medium-sized organ (e.g., water density). In general, five radiographic densities are listed—metal, bone, water, fat, and air—from most radiolucent (black) to most radiopaque or radiodense (white) ( Fig. 5-11 ). Of course, metal does not occur in the body naturally but may be present after surgery, dental work, or foreign body intrusion; or reflect the presence of overlying artifacts (e.g., necklaces or earrings). FIG. 5-11 Five radiographic densities. This is the radiograph of a baby’s bottle in which the lower third of the bottle is filled with water, the middle third is filled with with oil (fat), and the upper third is left open to air. A clavicle and ring are inserted into the beaker. The constituents resemble each of the five radiographic densities of air, oil, water, bone, and metal, listed from black (radiolucent) to white (radiodense). VISUAL SEARCH Image interpretation involves gathering visual information to produce specific perceptions. The attitudes, beliefs, biases, and expectations of the examiner influence both what is observed during visual assessment and what is concluded from those observations. Although film interpretation is truly an art, generally accepted sequential steps define the process of image interpretation ( Box 5-3 ). The first step is for the interpreter to become familiar with the study’s clinical rationale. Is a fracture suspected? Does the 65-year-old patient with unrelenting low back pain have a history of night pain, unexplained weight loss, or past malignancy? Next the images should be viewed completely with a thorough visual search path. A complete search path is used to ensure that all of the anatomy has been observed. The best search path is a unique one developed by the interpreter over time, which compensates for the interpreter’s inherent weaknesses in observation. For instance, if an interpreter has difficulty remembering to look at the sella turcica on a lateral radiograph of the cervical spine, the search path should be altered to emphasize that region; this will compensate for the interpreter’s inherent tendency to underinterpret that portion of the film. BOX 5-3 Steps in Radiographic Interpretation 1. Understand the clinical rationale for the study. 2. Search the images for abnormal findings. 3. List and define any abnormal findings. 4. Summarize any abnormal findings by either concluding on an obvious diagnosis (an Aunt Minnie) or attempting to identify a general pattern or gamut described by the abnormal findings. Selected radiologic patterns of abnormality are listed in Box 5-13 . 5. Integrate the radiologic findings and list of possible diseases that may explain these findings with pertinent data obtained from the history, clinical examination, laboratory testing, and further or past diagnostic imaging. The goal is to follow a systematic, rational process that narrows the list of radiologic and clinical considerations to identify a definitive diagnosis that will assist in successful patient management. ABCS of film interpretation. The ABCS of film interpretation describes a commonly taught generic search path for film interpretation. “ABCS” is a learning aid to prompt the interpreter to review all of the imaged anatomy by concentrating on four components in a fixed sequence: alignment, bone, cartilage (joint spaces), and soft tissue separately. By deconstructing the search path into manageable components (e.g., alignment and bone), the interpreter is less likely to omit aspects of the anatomy from the search path. Instead of following the ABCS format in direct sequence, some interpreters prefer to inspect the areas in other sequences, such as BCAS (bone, cartilage, alignment, and soft tissue) or ACBS (alignment, cartilage, alignment, and soft tissue). Alternatively, some interpreters like to employ a “free” search pattern that allows interpreters’ gaze to scan the anatomy in any sequence that grabs their visual attention. Regardless of the method (fixed or free), the search path must be comprehensive for reasons of accuracy, and concise for reasons of practicality. Use of checklists in film interpretation. Some interpreters, especially beginners, are helped by consulting checklists of structures to assist in film interpretation. In a general sense, the ABCS approach to film interpretation is a brief checklist, reminding and sequencing the visual path of the interpreter through the presenting alignment, bone, cartilage (joint space) and soft tissues. All of the visualized anatomy needs to be closely scrutinized for possible defects. BOX 5-4 BOX 5-5 BOX 5-6 BOX 5-7 BOX 5-8 BOX 5-9 BOX 5-10 BOX 5-11 and BOX 5-12 present developed checklists to ensure a comprehensive review of selected radiographic projections. Developing a truly all-inclusive checklist for each radiographic projection listed is not feasible. Instead the checklists enumerate the major technical considerations and anatomy (ABCS approach discussed in the preceding), and list problem areas that require extra attention. BOX 5-4 Interpretation Checklist for a Lateral Cervical Radiograph Patient information ▪ Review and verify the date of examination and patient information. Image quality ▪ Evaluate photographic properties: density, contrast, and noise factors (quantum mottle, fog, etc.). ▪ Evaluate geometric factors: size, shape, detail, and distortion. Patient positioning and technical defects ▪ Are there signs of positioning errors, motion artifact, static marks, or other technical defects? ▪ Are the films done recumbent or upright? Field of view ▪ Does the vertical field of view extend from the base of the occiput to below the C7 vertebra? ▪ Does the horizontal field of view include angles of the mandible to the C7 spinous process? Common artifacts ▪ Are there stems of eyeglasses, earrings, necklaces, clothing, and so on? Common foreign bodies ▪ Are there any dental fillings? Alignment ▪ Is the cervical lordosis maintained? ▪ Is the tip of the odontoid vertically centered over the C7 body? ▪ Are the articular pillars offset, suggesting facet dislocation, or do they closely overlap as usual? ▪ Are the posterior borders of the rami of the mandible generally overlapped? (Projectional distortion causes them not to be directly overlapped.) ▪ Are the seven vertical lines maintained? Line 1: along posterior tips of spinous processes Line 2: along spinal laminal lines Line 3: along posterior margins of posterior joints Line 4: along anterior margins of posterior joints Line 5: along posterior margins of bodies C2 to C7 (George’s line) Line 6: along anterior margins of bodies C2 to C7 Line 7: along posterior margin of pharynx and tracheal air shadows Bones ▪ Are radiodensity, size, shape, and configuration of each vertebra normal? • Vertebral body • Transverse process • Pedicle • Lamina • Spinal laminar junction line • Spinous process • Odontoid process of C2 ▪ Do the mandible, maxilla, and teeth appear normal? ▪ Are the radiodensity, size, shape, and configuration of the base of the skull normal? ▪ Is the sella turcica normal? ▪ Is the spinal canal maintained? Joint spaces ▪ Is the atlantodental interval increased (>3 mm in adults or 5 mm in children)? ▪ Are the intervertebral disc spaces well maintained? ▪ Are cervical disc spaces wedged to the anterior? ▪ Are the posterior joint surfaces parallel with visible joint spaces from C3 to C7? ▪ Is the intervertebral foramen maintained? ▪ Is the space between the occiput and the atlas, and the interspinous spaces from C2 to C7 maintained? Soft tissue ▪ Is the retropharyngeal space less than 5 mm at C2 and the retrotracheal space less than 20 mm at C6? (An in situ nasogastric tube will invalidate these measures.) ▪ Do the paranasal sinuses appear radiolucent? ▪ Is there physiologic calcification of the laryngeal cartilages? Problem areas ▪ Atlantodental interval, sella turcica, C7 spinous process, and so on ( Fig. 5-12 ) BOX 5-5 Interpretation Checklist for an Anteroposterior Lower Cervical Radiograph Patient information ▪ Review and verify the date of examination and patient information. Image quality ▪ Evaluate photographic properties: density, contrast, and noise factors (quantum mottle, fog, etc.). ▪ Evaluate geometric factors: size, shape, detail, and distortion. Patient positioning and technical defects ▪ Are there signs of positioning errors, motion artifact, static marks, or other technical defects? ▪ Are the films done recumbent or upright? Field of view ▪ Does the vertical field of view extend from the angles of the mandible to the apices of the lung? ▪ Does the horizontal field of view include several centimeters of soft tissue on either side of the spine? Common artifacts ▪ Are there eyeglasses, necklaces, hairpins, hair braids, clothing, and so on? Common foreign bodies ▪ Are there any dental fillings, surgical staples from carotid enterectomy, and so on? Alignment ▪ Is there a right or left cervical list or head tilt? ▪ Is there a right or left lateral curvature? ▪ Are the spinous processes generally aligned vertically? ▪ Is there a right or left laterolisthesis of any vertebrae? Bones ▪ Are the radiodensity, size, shape, and configuration of each vertebra normal? • Vertebral body • Uncinate processes • Transverse processes • Pedicles • Laminae • Articular pillars • Spinous processes • Odontoid process of C2 ▪ Are the radiodensity, size, shape, and configuration of the ribs normal? ▪ Are the radiodensity, size, shape, and configuration of the clavicle normal? ▪ Are the mastoid processes normal? ▪ Is the superior margin of the sternum normal? Joint spaces ▪ Are the intervertebral disc spaces well maintained? ▪ Are the uncinate joint spaces well maintained? ▪ Are the costotransverse joints normal? Soft tissue ▪ Is the piriform sinus, rima glottis, and tracheal air shadow midline? ▪ Does the paranasal sinus appear radiolucent? ▪ Are the apices of the lung clear of mass, infiltrate, or other defect? ▪ Is the aortic knob of normal configuration? ▪ Is there carotid artery calcification? ▪ Are the paraspinal tissues clear of mass or defect? Problem areas ▪ Lung apices, uncinate processes, upper ribs, and so on ( Fig. 5-13 ) BOX 5-6 Interpretation Checklist for an Anteroposterior Open-Mouth Cervical Spine Radiograph Patient information ▪ Review and verify the date of examination and patient information. Image quality ▪ Evaluate photographic properties: density, contrast, and noise factors (quantum mottle, fog, etc.). ▪ Evaluate geometric factors: size, shape, detail, and distortion. Patient positioning and technical defects ▪ Are there signs of positioning errors, motion artifact, static marks, or other technical defects? ▪ Are the films done recumbent or upright? Field of view ▪ Does the vertical field of view extend from above the tip of the odontoid to below the C2 spinous process? ▪ Does the horizontal field of view extend laterally to the tips of the transverse processes of the atlas? Common artifacts ▪ Are there artifacts such as tongue jewelry, hairpins, and so on? Common foreign bodies ▪ Are there any dental fillings, and so on? Alignment ▪ Are the widths of the lateral masses bilaterally comparable? ▪ Are the paraodontoid spaces symmetric? ▪ Does the lateral mass extend laterally beyond the margin of the superior articular processes of C2? ▪ Is the center of the C2 spinous process vertically aligned with the center of the odontoid process? Bones ▪ Are the radiodensity, size, shape, and configuration of the atlas normal? • Lateral masses • Transverse processes • Transverse foramen • Anterior arch • Posterior arch ▪ Are the radiodensity, size, shape, and configuration of the C2 segment normal? • Odontoid process • Body • Pedicles • Superior articular processes • Spinous process ▪ Are the radiodensity, size, shape, and configuration of the base of the occiput normal? ▪ Are the occipital condyles normal? ▪ Are the rami of the mandible normal? Joint spaces ▪ Is the occipitoatlantal joint space maintained? ▪ Are the atlantoaxial joints maintained? ▪ Is the C2-C3 disc space maintained? Soft tissue ▪ Is there ossification of the stylohyoid ligaments? Problem areas ▪ Odontoid process, alignment of the lateral mass, and so on ( Fig. 5-14 ) BOX 5-7 Interpretation Checklist for a Lateral Thoracic Radiograph Patient information ▪ Review and verify the date of examination and patient information. Image quality ▪ Evaluate photographic properties: density, contrast, and noise factors (quantum mottle, fog, etc.). ▪ Evaluate geometric factors: size, shape, detail, and distortion. Patient positioning and technical defects ▪ Are there signs of positioning errors, motion artifact, static marks, or other technical defects? ▪ Are the films done recumbent or upright? Field of view ▪ Does the vertical field of view extend from above T1 to below T12? ▪ Does the horizontal field of view extend from near the sternum to include the posterior angles of the ribs? Common artifacts ▪ Are there necklaces, hair braids, clothing, and so on? Common foreign bodies ▪ Are there any sternal wires, pacemaker, valve prosthesis, and so on? Alignment ▪ Is the thoracic kyphosis maintained? ▪ Is there any vertebral retrolisthesis or spondylolisthesis? ▪ Are the spinous processes generally aligned vertically? Bones ▪ Are the radiodensity, size, shape, and configuration of each vertebra normal? • Vertebral body • Pedicles • Spinous process ▪ Are the radiodensity, size, shape, and configuration of each rib normal? ▪ Is the spinal canal maintained? Joint spaces ▪ Are the intervertebral disc spaces maintained? ▪ Is the intervertebral foramen of normal size? Soft tissue ▪ Is the tracheal air shadow centrally located? ▪ Is the heart shadow generally of normal size and configuration? ▪ Are the lung tissues clear of mass, infiltrate, or other defect? ▪ Are the ascending, transverse, and descending segments of the aorta normal? ▪ Are the aortic-pulmonary window and hila defined and clear? ▪ Is the diaphragm of normal position? ▪ Is the gastric air bubble of normal size and location below the diaphragm? Problem areas ▪ Vertebral stature, lung tissue, hila, and so on ( Fig. 5-15 ) BOX 5-8 Interpretation Checklist for an Anteroposterior Thoracic Spine Radiograph Patient information ▪ Review and verify the date of examination and patient information. Image quality ▪ Evaluate photographic properties: density, contrast, and noise factors (quantum mottle, fog, etc.). ▪ Evaluate geometric factors: size, shape, detail, and distortion. Patient positioning and technical defects ▪ Are there signs of positioning errors, motion artifact, static marks, or other technical defects? ▪ Are the films done recumbent or upright? Field of view ▪ Does the vertical field of view extend from above T1 to below T12? ▪ Does the horizontal field of view include about 7 cm of soft tissue on either side of the spine? Common artifacts ▪ Are there necklaces, hair braids, clothing, and so on? Common foreign bodies ▪ Are there sternal wires, pacemaker, valve prosthesis, and so on? Alignment ▪ Is there a right or left lateral curvature? ▪ Are the spinous processes generally aligned vertically? ▪ Are there any right or left vertebral translations? Bones ▪ Are the radiodensity, size, shape, and configuration of each vertebra normal? • Vertebral body • Transverse processes • Pedicles • Laminae • Articular processes • Spinous process ▪ Are the radiodensity, size, shape, and configuration of the ribs normal? ▪ Are the radiodensity, size, shape, and configuration of the medial segments of the clavicles normal? ▪ Are radiodensity, size, shape, and configuration of the sternum normal? Joint spaces
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How to create and manage test cases with xray and jira.
Head of Solution Architecture and Testing Advocacy, Xray
Step-by-step instructions on how to write, specify, organize, and execute test cases
Eight-minute read. Complete in one session (two hours)
You are new to Xray Test Management. You've created a project and want to learn how to write, specify, organize, and execute test cases.
You’ve installed Xray in your Jira instance. Get started with Xray for Jira here.
You’ve created or added Xray to your project.
You have an active Jira project with the GitLab application installed and configured. Get started with Jira here.
What is a test?
A test is an abstraction of a test idea/scenario and a way to verify/validate associated requirement(s). It’s one or more checks, an experiment, or an investigation with the goal of obtaining information about a quality attribute of the test target.
A traditional, manual test involves a sequence of steps coupled with conditions or variables, test inputs, and expected results. It is intended to establish the quality, performance, and/or reliability of a piece within a system.
Usually, every requirement or objective of the test target is expected to achieve at least one test.
The success of a test is determined by comparing the expected and actual results.
A test can be:
- Scripted (e.g. test case or automated test) or exploratory
- Specified using Gherkin (scenario)
- Executed manually or through automation
- Linked to/cover one or more requirements
- Like any other Jira issue type, it can be labeled, prioritized, assigned to components, and commented on
Tests and testing in general don’t ensure quality. They provide information about quality.
100 percent coverage is a myth. Adding more tests doesn’t ensure better information about the quality that matters to you.
It’s often better to focus on assessing what stakeholders are concerned about, consider risks, and specify and perform testing based on these metrics.
There will always be some bugs. It’s important to understand what’s valuable so testing can focus on what threatens those values.
Test process in Xray
Xray allows you to plan, design, and execute tests, as well as generate test reports. Xray uses specific Jira issues types for this process.
Each testing phase allows you to use the following issues:
- Plan phase : Test plan issues
- Design phase : The specification is defined using precondition and test issue types. The organization of the tests can be defined using test sets
- Execute phase : Test execution issues
- Report phase : Test execution issues including built-in requirement coverage reports and custom issues using Jira Software tools
To start, it’s useful to add tests to a small project. You can use test issues to create tests for your requirements and execute ad hoc, unplanned test executions. Here’s how:
Step 1: How to write and specify tests
There are three default test types:
- Cucumber : Write tests in a business-readable domain and specific language (Gherkin)
- Generic : An unstructured test, without steps. This is a way to abstract and have visibility of traditional automated tests or exploratory tests
- Manual : A traditional test case composed of a list of steps that are scripted
Each test type has one of three kinds of tests:
Actions you can perform on Xray tests:
To create a new test issue follow these steps:
Step 1 : Click Create Issue at the top of the screen to open the Create Issue dialog box/page.
Step 2 : Select the Project . On Issue Type , select Test .
Step 3 : Type a Summary for the test and fill at least all mandatory fields marked with an asterisk.
Step 4 : When you are satisfied with the content of your test, click the Create button.
Step 2: How to organize tests
Organizing tests is a crucial part of daily testing activities. Since you might start with a large number of tests and your tests may grow over time, it’s important to organize them in an efficient and effective way that works for you.
Xray provides two different ways to organize your tests:
- Use the test sets issues
- Use the test repository
The test set is a simple way to create different groups of tests, since it is a flat list of tests. You may have as many test sets as you wish and a test may be included in multiple test sets. Test sets are ideal if you want to have full control over certain groups of tests.
Create test sets
To create a new test set issue:
Step 1 : Click the Create Issue at the top of the screen to open the Create Issue dialog/page.
Step 2 : Select the Project and on Issue Type , select Test Set .
Step 3 : Type a Summary for the test set and complete at least all fields marked by an asterisk.
Step 4 : When you are satisfied with the content of your test set, click the Create button.
The test repository is a tree-like organizational structure at the project level. It allows you to hierarchically organize tests within folders and sub-folders. This folder concept is common in some tools and resembles file organization in a computer's operating system.
Create a test repository
To create a test repository, create a new folder:
Step 1 : Click on the parent folder.
Step 2 : Click on the add icon at the top of the folders section.
Step 3 : Type the name for the folder on the create folder dialog.
Step 4 : Press "Create" to create the folder.
Step 3: How to plan tests
Test planning allows you to decide your testing strategy , including the issues you want to validate, how to validate them, if tests will be manual or automated, how resources will be allocated, and when and who will execute the tests.
Depending on several factors, you may want to prioritize some tests or focus on specific requirements.
Create a test plan
Here’s how to create a new test plan Issue:
Step 1 : Click Create on the top of the screen to open the Create Issue dialog box/page or press the " C " key on the keyboard.
Step 2 : Select the Project . On the Issue Type , select Test Plan .
Step 3 : Type a Summary for the test plan and fill out at least all mandatory fields marked with an asterisk.
Step 4 : When you are satisfied with the content of your test plan, click Create .
Step 4: How to execute tests
Test execution occurs between developing test scripts and reporting and analyzing test results.
A test execution is an issue type that aggregates a user-determined collection of tests. It monitors and verifies if tests work as expected in a target context and environment. The overall execution status, updated after each test is performed, informs you about the progress of the test execution, including which tests passed, failed, are being executed, or are waiting to be performed.
Create a test execution issue
Step 1 : Click the + at the left of the screen to open the Create Issue dialog box.
Step 2 : Select Project . On Issue Type , select Test Execution .
Step 3 : Type a Summary for the test execution and fill out at least all mandatory fields marked with an asterisk.
Step 4 : In the Create Issue dialog populate the test execution custom fields provided by Xray, including the Begin/End date and Revision .
Optional : To create a series of similar test executions within the same Project , check Create another at the bottom of the dialog.
Step 5 : When you are satisfied with the content of your test execution, click Create .
For more detailed information on how to create and manage test cases in Jira and Xray, check out the Xray Academy .
See more integrations for Atlassian Open DevOps .
Sérgio Freire is the Head of Solution Architecture and Testing Advocacy for Xray, a cutting-edge Test Management app for Jira. He works closely with many different teams worldwide to help them achieve great, high-quality, testable products. He believes that by understanding how organizations work, processes and quality can be improved while development and testing can "merge" and act as a unique team, with a common goal: provide the best product that stakeholders need.
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Radiology Reports: Who Reads Them, Who Writes Them, and How Do They Help?
That’s a simplification, but the general comparison holds. When you go in for a scan (whether it’s an MRI , an X-ray, computed tomography, or any other imaging modality), technologists obtain the images. When the images are complete, a radiologist examines, or “reads,” them, and writes a report indicating clinically significant details. That report then gets sent out to the referring physician and, if the patient requests a copy, to the patient themselves.
Pretty simple, right? The radiology report is a crucial diagnostic tool, the considered opinion of a medical expert, and a vital part of your health records. A radiologist writes them, your doctor reads them, and they can help by creating a clearer picture of a pathology. That will ultimately improve your care. There’s one more person who reads radiology reports in this era of electronic health records, though, and that’s you, the patient. Here’s what to look for when you gain access to your own radiology report.
Reading and Understanding Radiology Reports
First off, have a medical dictionary or internet access before you begin reading your radiology report. There’s no way to write a clear, actionable analysis without resorting heavily to medical lingo, which can often look like a foreign language to lay readers.
Most radiology reports follow a familiar template. Here are the sections found in the typical radiology report:
This introductory section describes the imaging modality used to create the images that inform the report. It will tell readers that the patient had an MRI, an X-ray, a CT scan, or whatever the referring doctor ordered. It will mention any contrast agents used and the area of the body scanned.This section should also include the time and date of the procedure. That’s very important, because later studies can refer back to this one to see how masses within the body are moving or changing over time.
Patient’s Clinical History
This section describes the patient and is a vital source of context for understanding diagnostic images. It should describe the age and sex of the patient, as well as any past or current diagnoses.The Clinical History section is also where the radiologist will note the reason the patient was referred for imaging.
Studies Used for Comparison
If the radiologist has access to previous scans and reports, they will note which ones they used for comparison. Differences over time can be valuable diagnostic clues.
Here’s where the radiologists get down to details about the technical process of obtaining the scan. This section isn’t really written for referring physicians or for patients; it’s far too highly technical to be useful to anyone other than a trained radiologist. And that’s who the Technique section is for, later radiologists who will look back through the study to plan a new imaging procedure.
Clinical Findings of the Imaging Study
Now we’re getting somewhere. The Findings section of a radiology report will list each organ or area of the body involved in the scan. They will indicate whether those body parts look “normal” or “abnormal.”The significance of the Findings content is usually found in the next section, which brings us to…
If you could only read one section of your radiology report, this is the one you’d want to look at. Here’s where the radiologist ties together all the previous elements of the report to list possible diagnoses. They also suggest further actions.They might recommend another imaging study, a single diagnosis, or a list of possible diagnoses called a “differential diagnosis.” This is the section that physicians will spend the most time with, and it’s also what most patients are looking for.
We Bring The Good Technical Report To Life.
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Look for an effusion. There is generalized osteopenia. In this article we will focus on. These zones do not equate to lung lobes eg.
One format for writing an x-ray report is to consider the following aspects in turn. The left lung has three zones but only two lobes. Avoid if clinically indicated Dont hedge.
The chest x-ray is the most frequently requested radiologic examination. Reports should be clear correct concise complete consistent and have a high confidence level. Document the call in the report.
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Juries do not understand poorly Dont be vague. Remember that the knees of younger children will look different as the patella forms and the ossification centres form. In A an example of an analysis of abnormal spinal alignment of the neck in the front view is provided and in B an example of an analysis of abnormal spinal. Check the hemidiaphragms for position the right is commonly slightly higher than the left due to the liver and shape may be flattened bilaterally in chronic asthma or emphysema or unilaterally in case of tension pneumothorax or foreign body aspiration.
Volume loss resulting in displacement of diafragm fissures hili or mediastinum. In fact every radiologst should be an expert in chest film reading. Lumbosacral spine X-rays are the most commonly used to determine the cause of lower back pain.
The other findings may be reported as additional diagnoses. Inspect the lung zones ensuring that lung markings are present throughout. There are OA changes seen at the first CMC joint with subchondral sclerosis and joint space narrowing.
Chiropractic X Ray Report Template Radiology How To Write Joining After Earned Leave Example Of Laboratory Pdf
However a visual image does not provide the details of your misalignments. Sharply-defined opacity obscuring vessels without air-bronchogram. Brief description of the radiographic findings. In assessing a chest X-ray theres a lot to consider and a lot to remember to look for.
X-RAY Report of Findings Summary By looking at your x-ray views compared to the normal views in the preceding photographs you get a visual idea of what is wrong with your spinal alignment which Healthcare Practitioners term vertebral subluxations. Make the referring physician look good – A common phrase fracture is poorly aligned should be avoided. One should barely see the thoracic vertebrae behind the heart.
Hands and wrists two views of the right and left hand and wrist were obtained. This is a basic article for medical students and other non-radiologists. Indeed it is foolish to try.
Abdominal X Ray Report Template 3 Professional Templates How To Write A Good Abstract Apa What Are The Emerging Issues In Accounting
The primary diagnosis is wheezing since it was the reason for the patients visit. These x-rays take pictures of the 5 bones of the lower back lumbar vertebrae and a view of the 5 fused bones at the bottom of the spine sacrum. In the real world of the hospitals the X-ray is usually labeled in some way either on the image itself or in the report especially if it was taken via the portable AP technique. The report should communicate relevant information about diagnosis condition response to therapy andor results of a procedure.
Measure the distance from the medial end of each clavicle to the spinous process of the vertebra at the same level which should be equal. Normal anatomy and variants. X-RAY Report of Findings Figure 6.
Put yourself in the referring physicians shoes. The report is the written communication of the radiologists interpretation discussion and conclusions about the radiologic study. In the front x-ray views lines are drawn through the centers of mass of each spinal vertebra to measure your abnormal spinal alignment.
The Charming Sample Report To Copy Of This Document Click Inside Chiropractic X Ray Template Images Word Free Book Templates What Is Subject Knowledge How Write A Killer Abstract
With an increased work-load and a shortage of radiologists the ideal of reporting on all X-ray examinations is one few of us can accomplish. Be a journalist and not a reporter. 1- The term without substitutions or modifications Critical Result or Unexpected Finding will be used as a lead off to the documentation statement. A patient is referred for a chest x-ray because of wheezing.
The key-findings on the X-ray are. 2- The name of the person receiving the report and asserting back to the radiologist that the nature and implications of the communication is understood is documented. See the the anatomical landmarks on the diagrams below.
The Astounding Xray Report Template 15 Disadvantages Of In Chiropractic X Ray P Professional Templates What Does A Technical Accountant Do How To Write Background Note
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Creating an X-Ray Report
Morningstar’s signature account analysis tool shows high-level account information (asset allocation, style box diversification, stock stats, etc.) in a thorough, yet easy to understand, report.
To view an interactive annotation of this report, click here .
There are two ways to create an X-Ray Report.
From the accounts spreadsheet
In the left navigation pane, click Portfolio Management . The Portfolio Management tab opens.
In the left-hand column, click Accounts . The Accounts spreadsheet opens.
Select the account by clicking in the check box to the left of the account name .
From the Action menu, point to Reports , then Analytical , then click X-Ray . The report is generated.
Along the top of the report are four tabs for account details: Asset Allocation , Stock Sectors , World Regions , and Top 10 Holdings .
If desired, you can save the X-Ray PDF. Enter a name in the Report Title box. Click Save . The X-Ray is saved and stored in the Reports area for the individual account and client, as well as the Reports area for your entire practice.
From within an account
In the left-hand navigation pane of an open account, click the arrow next to X-Ray.
C lick on one of the four subheadings ( Asset Allocation , Stock Sectors , World Regions , and Top 10 Holdings ) to open the report.
If desired, you can save the X-Ray PDF. Enter a name in the Report Title box.
Click Save . The X-Ray is saved and stored in the Reports area for the individual account and client, as well as the Reports area for your entire practice.
©2023 Morningstar. All Rights Reserved.
Introduction The radiology report represents the sum of a radiologist's highest level of synthesis and insight into a patient's condition and is the most important way that radiologists contribute to patient care. In most instances, it is the only communication with referrers.
The radiology report represents the sum of a radiologist's highest level of synthesis and insight into a patient's condition. It is the most important product that radiologists generate to help direct patient care. Despite the self-evident importance of clear and effective radiology reporting, radiologists usually receive little or no formal reporting education during training. Instead, it ...
Be brief. Clinicans have been asked what they want: "brief description of the radiographic findings." Most important finding first. Normal except for cancer RLL is unacceptable. The physician may stop at normal. Quantitate Quantitate Quantitate. Measure if possible or use qualifiers- mild, moderate, severe. Compare, Compare, Compare.
PDF Copy The written radiology report Dr. Wilcoxis an Interventional Radiologist, East Texas Radiological Consultants, Athens, TX. The written radiology report is the most critical component of the service provided by a radiologist. It constitutes the formal documentation and communication of the results of a radiologic
If readers want details they can refer to the descriptive section of the report. Impression: "Pneumonia" is preferable to repeating that it is a "patchy posterior segment left upper lobe pneumonia.". Brief reports do not require "Impressions.". Unfortunately, the definition of "brief" is variable [ 3, 7 ].
Electronic Health Records. The radiologist writes the report for your provider who ordered the exam. Typically, the radiologist sends the report to the person who ordered your test, who then delivers the results to you. Many patients can now access their electronic health records online. These records include radiology reports.
What should I use to write with? You need to use a pen with black ink, as this is the most legible if notes are photocopied. Patient details For every new sheet of paper your first task should be to document at least three key identifiers for the relevant patient: Full name Date of birth Unique patient identifier Home address
1 of 29 How to write a decent radiological report Nov. 17, 2012 • 0 likes • 10,496 views Download Now Download to read offline Report The lecture is for junior radiologists ,to give tips for writing a good and credible radiology report. Ahmed Bahnassy Follow Consultant Radiologist at Thosson Hospital-HIO-Alexandria Advertisement Advertisement
Edit article Citation, DOI, disclosures and article data Describing a fracture is a basic requirement when making an assessment of a plain radiograph. There are many ways to approach the assessment of the radiograph; this is just one approach. I: Describe the radiograph What radiograph (or radiographs) are you looking at?
The report should communicate relevant news with medical, condition, responses to therapy, and/or results of a procedure performed. 12. The written report should also answer either clinical question raised by the requesting patient-care provider that is relevant to the radiologic study.
The Lumbar series reveals in the AP view a mild/moderate right/left rotatory curvature of the lumbar spine, with left/right spinous process rotation from T- to L-. There is a --mm. leg length iniquity on the left/right. There is anterior/posterior rotation of the bilateral/left/right ilia on sacrum.
Lumbar spine X-rays are one of the most commonly requested radiographic investigations of the spine, however, it should be noted that projectional radiography has limitations and other imaging modalities such as MRI and CT should be considered if further evaluation is required.
Cases and figures. Figure 1: three rings. Case 1 (a): subcaptial fractured neck of femur. Figure 2: joint spaces. Case 1 (b): intertrochanteric fracture. Figure 3: acetabulum. Case 2: pubic ramus fracture. Figure 4: acetabular radiological anatomy. Case 3: complex open book fracture.
X-Ray Report Sample #1 HANDS AND WRISTS - TWO VIEWS: Hands and wrists, two views of the right and left hand and wrist were obtained. There is generalized osteopenia. There are OA changes seen at the first CMC joint with subchondral sclerosis and joint space narrowing. Ulnar styloids appear intact. There is no chondrocalcinosis.
An x-ray beam that traverses a thin bone may appear more radiolucent (sometimes termed less dense) than when the same x-ray beam traverses a medium-sized organ (e.g., water density). In general, five radiographic densities are listed—metal, bone, water, fat, and air—from most radiolucent (black) to most radiopaque or radiodense (white ...
Step-by-step instructions on how to write, specify, organize, and execute test cases Time Eight-minute read. Complete in one session (two hours) Audience You are new to Xray Test Management. You've created a project and want to learn how to write, specify, organize, and execute test cases. Prerequisites You've installed Xray in your Jira instance.
Components of a Radiology Report Who, when, what, how, and why Who: identify patient name, number, date of exam, type of exam How: identify technique of exam (ie projections used, contrast given, slice thickness, scan interval, etc) Comparison exams with dates (if available)
Most radiology reports follow a familiar template. Here are the sections found in the typical radiology report: Exam Type This introductory section describes the imaging modality used to create the images that inform the report. It will tell readers that the patient had an MRI, an X-ray, a CT scan, or whatever the referring doctor ordered.
One format for writing an x-ray report is to consider the following aspects in turn. The left lung has three zones but only two lobes. Avoid if clinically indicated Dont hedge. The chest x-ray is the most frequently requested radiologic examination. Reports should be clear correct concise complete consistent and have a high confidence level.
C lick on one of the four subheadings (Asset Allocation, Stock Sectors, World Regions, and Top 10 Holdings) to open the report. Click to generate and print the PDF report. If desired, you can save the X-Ray PDF. Enter a name in the Report Title box. Click Save. The X-Ray is saved and stored in the Reports area for the individual account and ...
and the lord ended the battle || nsppd || 9th june 2023