Radiological reports
Elizabeth Stokell MA VetMB CertVR MRCVS
Department of
Clinical Veterinary Medicine
University of Cambridge
Madingley
Road
Cambridge
The film report should be organised according to
the following sections:
1. Subject
Describe the subject with respect to the following:
- Species
- Breed/Type (size of patient, skull type)
- Age (estimate according to appearance of physes, ossification centres and
dentition)
- Sex (if radiologically apparent)
- Body condition
2. Radiographic projections
- Identify the number of films
- Ensure that all the projections refer to the same patient
- Check whether the radiographs were all made at the same time, or are
serial radiographs
- The projection is named according to the direction of the primary beam
through the patient
- Identify, if possible, whether a grid has been used
3. Radiographic quality
Poor quality radiographs may be difficult or
impossible to interpret, or may be misleading and mimic disease
conditions.
Comment on the following features which affect the quality of the
radiograph:
- Positioning of the patient
- Centring of the primary beam with respect to the patient
- Collimation of the primary beam with respect to the film and the patient
- Exposure
- Development
- Labelling
- Artefacts
4. Radiological report
Recreate the radiograph for someone unable to see
it.
Describe different projections of the same area at the same
time.
Describe any abnormality according to its roentgen signs:
- Size
- Shape
- Position
- Number
- Opacity
- Margination
- Architectural pattern
List the abnormal findings.
N.B. Remember
to read the entire film.
5. Diagnosis/Differential diagnoses
A diagnosis may be readily apparent,
or a number of differential diagnoses may have to be considered for each
abnormality.
List differential diagnoses in order of likelihood, with
qualifying statements as to any differential's particular likelihood in this
patient.
6. Further diagnostic tests
Comment on what further diagnostic tests may
allow a differential diagnosis to be made.
Consider further radiography:
- Additional projections of the region of interest
- Additional projections of other parts of the patient
- Positional or stress radiography
- Contrast studies
- A follow-up study at a later date
Consider other imaging
modalities:
- Radiography with image intensification
- Ultrasonography
- Nuclear scintigraphy
- Computed tomography
- Magnetic resonance imaging
Consider other diagnostic tests:
- Physical examination
- Clinical pathology
Radiographic interpretation is an art as well as a science. It is a skill
that may be learnt by many clinicians. The more organised and analytical the
approach to the radiograph, and the more feedback and experience obtained, the
more astute the evaluator becomes in diagnostic radiology.