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Report Writing

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Report Writing Robert Tatum, DC, DACBR Associate Professor Radiology Diagnosis Department Palmer College of Chiropractic Why do we imaging patients? – PowerPoint PPT presentation

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Title: Report Writing


1
Report Writing
  • Robert Tatum, DC, DACBR
  • Associate Professor
  • Radiology Diagnosis Department
  • Palmer College of Chiropractic

2
Jean Martin Charcot, 1825-1893 Disease is very
old and nothing about it has changed. It is we
who change as we learn to recognize what
was formerly imperceptible. De LExpectation en
Medicine
Turn everything into an Aunt Minnie whenever
possible by looking at films, looking at films,
and looking at films
3
  • Why do we imaging patients?

Provide reliable anatomical, morphological
physiological information to effect treatment
Treatment should be better than the natural
history of the disease
4
Parameters depend on what you are looking for
5
Diagnostic Accuracy in the Interpretation of
Abnormal Lumbosacral Radiographs
71
70
62
52
45
31
28
20
6
0
10
20
30
40
50
60
70
80
John AM Taylor DC DACBR et al
Spine Vol 20 No 10 1995
6
Report Writing
  • part of the patients medicolegal record
  • provides a comparison with previous or later
    examinations
  • provides a record if radiographs are lost
  • resume of contraindications or indications
  • evaluate radiographs in the proper environment
  • develop a consistent search pattern

7
The Reading Room
  • Should be quiet and darkened without
    distractions.
  • Provide enough illuminators so that all films of
    the region In question can be viewed. This is
    important so that a three dimensional aspect can
    be perceived.
  • Hotlight examination of relatively over-exposed
    regions is an absolute must.
  • Remember that ALL areas within the collimated
    field of the radiograph are to be accounted for.

8
Viewboxes
  • have enough to view all the anatomy at one time
  • at least two 4 over 4s
  • hot light an absolute necessity

9
Viewing equip. and resources
  • View stations
  • Hot light
  • Ruler
  • Magnifying Glass
  • Textbooks

10
Image Presentation
Chiropractic/Surgical
Anatomic
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I am so bad
13
I am so bad
14
Report Writing
  • reports should contain the following items
  • heading
  • clinical information (debatable)
  • findings
  • diagnosis/differential
    diagnosis/conclusions
  • recommendations
  • signature

15
Report Writing
  • every radiographic examination MUST have a
    radiology report generated
  • heading date of exam, date of report, patient
    information, views
  • clinical information may help with the
    clinical/radiological correlation but it is
    debatable on its use in reports

16
Report Writing
  • findings a description of what you see written
    in paragraph full sentence format, utilizing the
    ABCS
  • impression or diagnosis (DDx) or conclusions
    listed 1,2,...
  • recommendation further diagnostic studies or
    referral

Last paragraph of incidental stuff
17
Findings
  • the body of the report
  • contains a written description of the relevant
    normal and abnormal findings
  • using full sentence paragraph format
  • does not contain diagnoses
  • usually divided into the ABCS BCAS, etc
  • used as a SEARCH pattern
  • use a flexible search pattern, particularly of
    related signs

18
Findings
  • A alignment (C,T, L)
  • B bone (C,T, L)
  • C cartilage (C,T, L)
  • S soft tissues (C, T, L)
  • Cervical ABCS
  • Thoracic ABCS
  • Lumbar ABCS

19
Findings
  • Decreased anterior vertebral body height is noted
    at C-7.
  • A small osteophyte is noted at the anterior
    inferior aspect of C-5 and possibly C-4. Slight
    sclerosis is noted involving the C-7/T-1
    posterior joints. There is slight decreased disc
    height noted at the C4-C-7 levels.

20
Findings
  • The cervical lordosis is reduced. Slight anterior
    weight bearing is noted involving the cervical
    spine.
  • The prevertebral soft tissues and the remaining
    soft tissues are within normal limits.
  • Incidentally noted is an artifact overlying C-1

21
Impressions
  1. Compression fracture at C-7. (discuss new, old,
    unknown age, etc)
  2. Early DDD at C-4 thru C-7 with early posterior
    joint arthrosis at C-7/T-1.
  3. Cervical hypolordosis
  4. Slight anterior weight bearing

22
Recommendations
  • Depends on if you know if it is new, old or
    unknown
  • New An orthopedic consultation is needed. With
    Specialized imaging as needed.
  • Unknown Review old films, history, clinical
    information and special imaging as needed
  • Old Correlate clinically with follow up studies
    as needed.

23
Findings
  • does not have to follow the ABCS format but may
    be BCAS, SBAC, etc
  • try to do clinically relevant stuff first
  • it is a search pattern to look at the entire film
  • if the B and the C category are both
    degenerative/arthritic it is okay to put them
    together into the same paragraph (eg, osteophyte
    and decreased disc height at C-5DDD)

24
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Findings
26
  • Related findings of a pathological or disease
    process can go and probably should go in the same
    paragraph
  • eg, you might combine a
  • B and a C
  • or a B and A
  • or a B and an S
  • or an S and a B
  • or a BAS,
  • Or a BASC
  • etc etc etc

27
  • If related BCAS stuff are combined into a related
    BCAS type paragraph, then there should be a
    separate and distinct paragraph for the BCAS NON
    related stuff
  • e.g.,
  • If you do an arthritic related BC paragraph you
    would still need a separate B and a separate C
    paragraph for all non related (non arthritic) B
    and C stuff

28
DEMANDS
  • The clinic wants you to use the BCAS format if
    possible (based on clinical relevance.)
  • Bony and cartilage changes usually influence
    alignment changes

X
BC, B, C, A, S Or B, BC, C, A, S Or BCS, B, C,
A, S Or etc
29
The clinic demands you to use the BCAS format if
possible (based on clinical relevance.)
30
Findings
  • try to use commonly accepted terminology
  • do not use listings
  • try to be as descriptive as you can
  • someone should be able to achieve the diagnosis
    by just reading your findings
  • some findings are also a diagnosis
  • the cervical lordosis is reduced (finding)
  • cervical hypolordosis (dx)

31
Impressions
  • diagnoses or differential diagnoses
  • listed numerically 1, 2, 3,..
  • listed in order of clinical significance
  • order of significance at times is debatable
  • cervical hypolordosis vs lumbar curve
  • short precise statements (dx/ddx)
  • try to be specific and grade conditions
  • mild degenerative disc disease at C5, etc

32
Impressions
  • sometimes a finding will be repeated as a
    diagnosis
  • sometimes you may not be sure of a diagnosis and
    you would repeat the finding with qualifiers such
    as suggestive of... or consistent with..., etc
    (pathologic fx)
  • last impressions are things that are
    incidentally noted such as ponticle, etc

33
Impressions
34
Recommendations
  • further tests that may be needed to support or
    clarify a diagnosis
  • lab studies
  • specialized imaging
  • concurrent consultations or referrals
  • technical comments
  • do not include chiropractic case management
    options

35
Recommendations
36
Report Writing
  • spine studies need a single report
  • extremities and chest need separate reports
  • reports must be signed by the doctor that
    generates the report

37
Report Writing Chest
  • SBCA
  • Is the technique
  • okay

38
Report Writing/Chest
  • if no abnormalities are detected
  • your report would stress the normal findings
  • SBCA type format.chest example
  • The mediastium is midline and there is no
    evidence of cardiomegaly. The costophrenic angles
    are clear. The lung fields are well aerated and
    without evidence of mass lesion or infiltrate.
    Visible infradiaphragmatic soft tissues are
    unremarkable. The visualized soft tissues of the
    thorax are within normal limits.

39
Report Writing/Chest
  • The bone density is adequate. The osseous
    structures unremarkable and the visualized joint
    spaces are within normal limits.
  • A slight right thoracic curvature is noted.
  • Conclusions
  • 1.No definitive abnormalities of the chest are
    detected
  • 2. Slight right thoracic curvature
  • Or
  • 1. No definitive abnormalities of the chest are
    detected
  • other than a slight right thoracic curvature
  • Recommendations

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47
  • Anatomical considerations

48
  • If everything is normal
  • STRESS the positives
  • Using the ABCS type format or BCAS
  • Talk about what you should be looking at using
    the search patterns

49
68 year old with unrelenting neck pain and upper
extremity numbness
Findings, Diagnosis and recommendations?
50
Chordoma
68 year old with unrelenting neck pain and upper
extremity numbness
Findings, Diagnosis and recommendations?
51
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54
R
Impressions 1. 2..
Recommendations 1. Review prior films if
available, BCP and MRI examination as needed.
55
R
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58
Most pathology will
  • Change or alter architecture/structure/anatomy
  • Increase or decrease density

The hardest part is knowing what is normal or
perceived as normal
Looking at films, looking at films and by looking
at films
And of course having diagnostic quality
radiographs is a must
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