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. 2010 Oct 1;7(Fall):1a.

Table 1.

Examples of Radiology Reports

Type of Report Radiology Report
Acute fracture Clinical History: r/o acute process
Report: LEFT WRIST AND LEFT FOREARM:
FINDINGS:
Three standard views of left wrist and two views of left forearm were obtained. The latter consists of lateral and oblique views without straight AP view.
Impression:
  • 1. There is what appears to be Smith's fracture affecting the left wrist. It consists of impacted comminuted fracture of distal left radial metaphysis having dorsal angulation at the fracture site as well as avulsion fracture of ulnar styloid process. The fracture affects neighboring radiocarpal as well as inferior radioulnar articulations.

  • 2. Small cortical avulsion fracture is also noted on lateral view of wrist at carpo-metacarpal articulation, probably at 3rd carpometacarpal articulation.

NOTE: Presence of an accessory ossicle dorsally opposing the triquetrum or lunate.
  • 3. Low-grade osteoarthrosis at left 1st carpo-metacarpal articulation as well as intermetacarpal articulation between 1st and 2nd.

  • 4. The rest of radius and ulna are normal.


Fracture negation Procedure: KNEE 3 VIEWS
Clinical History: S/p fall from ladder with right hip fracture. Since then also with right knee swelling and knee that “gives out”. Prior films showed effusion and narrowed joint space. Appreciate re-evaluation.
Report: RIGHT KNEE THREE VIEWS
Impression:
There is no acute fracture or dislocation. Mild patchy osteopenia. Probable small volume suprapatellar joint effusion. Mild patellar spurring.

Negation of acute fraction by age of fracture Procedure: CALCANEOUS 2 VIEWS
Clinical History: SP FX CALCANEOUS
Report: See impression.
Impression:
Compared to the prior study of 1/12/99 there is no significant change in the deformity of the calcaneus consistent with an old fracture which has undergone complete healing. The adjacent bony structures appear intact.

Implicit negation Procedure: FOOT 3 OR MORE VIEWS
Clinical History: 49 yo b m w cc of bilateral foot pain. please eval thanks.
Report: See Impression.
Impression:
BILATERAL FEET: No traumatic, arthritic, or developmental abnormality is discernible.