iRADiX

The Art and Science of Reporting in Radiology: Part 6

How to conclude the report?

What do you call it?

Call it “Summary”, “Impression”, “Conclusion”, “Opinion”, or “Comment” (I call it “Summary” in this discussion), but avoid "Diagnosis", because diagnosis is more specific, and is a combination of clinical, radiological, biochemical, microbiological, and histopathological factors.

Summary is not mandatory.

Not all reports should have a summary. If the main report itself is short and precise, there is no need to repeat the same thing again in summary.

Summary needs to be short and precise.

It is a medicolegal requirement on the part of the clinician to read the whole report. Despite, most of the clinicians rely on summary only. Hence, summary should be short and precise, should answer the clinical questions, and/or shows an unexpected clinically relevant finding. There is no need to repeat the whole episode of the main report in the summary too (just like some of the TV serials' "recaps", which are as long as 10 minutes!). Some of the orthopaedicians and neurosurgeons do not bother to read the report which is all together a different issue.

Summary addresses the clinical question, contains clinical relevant conclusion, and ignores irrelevant positive incidental findings.

Example: if the request asks for pulmonary mass, the summary should specifically state whether mass present or not.

Example: CT chest, abdomen and pelvis with a history of colonic cancer has following findings (from top to bottom): 2 thyroid nodules in a retrosternal thyroid, abberent right subclavian artery, pulmonary emboli, multiple lung metastasis, multiple liver metastasis, multiple gall stones, ascites, degenerative lumbosacral spine, and haemangioma in L3 vertebral body. I would put my “summary” as follows:

“In a known case of colonic carcinoma, there are multiple liver and lung metastases with generalised ascites, which is also likely to be malignant. Bilateral pulmonary emboli in the lobar branches need urgent clinical attention.”

I would not put other findings in my “conclusion”; they are there in the “main report”.

More importantly, I would pick up the phone and ring the relevant team to tell about the pulmonary embolism which needs urgent anticoagulation, and I would also document the communication in my report.

Commit, even if your opinion may turn wrong.

Everyone make mistakes. Radiological report is a small part of clinical investigations. A wise clinician knows how much weight to attach to a radiology report, when he/she is making the complete diagnosis.

Summary is for clinicians.

Summarise in words which clinicians understand. The main report is always better understood by fellow radiologists, and is very useful for the radiologist who is comparing the previous images.

Example: If a CT shows focal fluid attenuation area with thick wall enhancement, then summarise it as “abscess” rather than “fluid attenuation cystic lesion.

Do not make too many recommendations, especially the non-radiological ones.

If another radiological investigation is capable of answering the radiological dilemma of the current investigation, and can give more definitive answer, then do not hesitate to recommend it. It not only helps the clinician to take next relevant step in establishing the diagnosis, but also safeguards you medicolegally.

Example: Illdefined low attenuation area in the left centrum semiovale may be a white matter infarct, but in a 30 year old lady, do not hesitate to recommend MRI to look for demyelination.

If another radiological investigation might help to clarify the doubt of current investigation, but clinically not going to change the management, then one can suggest it in summary.

Example: A few rounded low attenuation lesions in the liver are most likely to represent “simple cysts”, but suggesting ultrasound would be useful, if the patient is known to have a malignancy.

When recommending a non-radiolgical investigation, be extra cautious or your ignorance may exposed.

Use “clinical correlation is needed” sparingly.

The terms like "further clinical correlation is suggested" and "CT is suggested, if clinically indicated" are too defensive way of practicing radiology, and should avaoided as much as possible. These kind of sentences should be reserved if you think clinical correlation makes a difference in reducing differential diagnosis. Whenever you feel like writing “further clinical correlation is suggested”, be specific about “what further clinical correlation is needed”

Example: In reporting a HRCT of an interstitial lung disease, “further correlation with occupational history is suggested” sounds better than “further clinical correlation is suggested”.

Add a personal touch.

Adding personal touch is a great way of building a good rapport with the referring clinician. It also makes you sound you are an experienced radiologist.

Examples: "I think this is unlikely to be any clinical significance". “In my opinion, this is tuberculosis, unless proven otherwise”. “I would suggest MRI of the brain”. “I explained the risks and benefits to the gentleman and took a written consent for ultrasound guided biopsy”.

Keep your report open-ended.

When a radiological investigation is performed and reported, do not presume the patient no longer belongs to you, and leave everything back into the hands of the referring clinician. Hence, do not shut the door of the report, keep it open. Open-ended summaries not only increase the rapport with the referring clinician, but also can, to some extent, can safeguard against medico-legal issues.

Examples: “I am more than happy to review the findings if you can provide the previous CT imaging".

I wish to thank one and all for the encouraging words while writing this series of “reporting in radiology”. I am indebted to the below mentioned articles to articulate my thoughts and have taken liberty to take a few ideas from these articles.

On a lighter note, I sign of this series with these 2 radiological reports which I came across in the UK.

REPORT 1:

Clinical information: ? Fracture neck of Radius

Report: Yes.

REPORT 2:

Clinical information: cough - ? cause

Chest X-Ray:

Merry Christmas (to the referring doctor)! The lungs are clear and your patient can have a good Christmas this year.

References:

1. Radiology reports: How much descriptive detail is enough?, McLoughlin RF et al. AJR 165, 803-805
2. Language of the radiology report: primer for residents and wayward radiologists. AJR 175, 1239-1242
3. Style guidelines for radiology reporting: a manner of speaking, AJR 180, 327- 328