Radiology report templates and examples

Examination: PA and lateral chest radiographs.

Comparison: None available.

Findings: The cardiomediastinal silhouette is within normal limits in size and contour. No focal air-space opacity or significant interstitial abnormality is identified. No pleural effusion or pneumothorax is present. No acute osseous abnormality is identified on the included images.

Impression: No acute cardiopulmonary abnormality.

Example impression: No intracranial mass, acute infarction, hemorrhage, or pathologic mass effect is identified. Ventricles and sulci are appropriate for age. Brain parenchymal signal is within normal limits. This conclusion applies to the routine noncontrast protocol; a pituitary, epilepsy, or cranial nerve question requires the appropriate targeted examination.

Technique: Multiplanar, multisequence MRI of the lumbar spine was performed without intravenous contrast.

Comparison: None available.

Findings: Lumbar lordosis and vertebral alignment are preserved. Vertebral body heights and marrow signal are within normal limits. Intervertebral disc heights and signal are preserved. No disc herniation, spinal canal stenosis, lateral recess narrowing, or neural foraminal stenosis is identified at the evaluated levels. The facet joints and posterior elements are unremarkable. The conus medullaris terminates at a normal level and demonstrates normal signal. No abnormality of the cauda equina roots is identified. No significant abnormality is present in the paraspinal soft tissues.

Impression: Lumbar spine MRI within normal limits.

The liver is normal in size and contour with homogeneous echogenicity. No focal solid or cystic lesion is identified. The intrahepatic bile ducts and common bile duct are not dilated. The gallbladder is adequately distended with normal wall thickness. No stone or sludge is identified. The visualized portions of the pancreas are unremarkable. The spleen is normal in size and echotexture. Both kidneys are normal in size and contour with preserved cortical thickness and echogenicity. No hydronephrosis or definite calculus is identified. The urinary bladder is adequately distended and shows no focal wall or intraluminal abnormality. No free fluid is identified in the abdomen.

Impression: No significant sonographic abnormality in the abdomen.

Example impression: No acute CT abnormality is identified in the abdomen or pelvis. There is no focal solid-organ lesion, bowel obstruction, free air, free fluid, or hydronephrosis. This conclusion is limited to findings assessed on a portal venous phase examination and should be adapted to the case-specific question.

Example impression: The uterus is anteverted and normal in size, with preserved myometrial signal and zonal anatomy. Endometrial thickness is appropriate for the clinical context. Cervical stroma is intact. Both ovaries have normal location and morphology, without a suspicious adnexal mass. No pelvic lymphadenopathy, free fluid, or conspicuous deep infiltrating endometriosis is identified.

Example impression: The adequately distended bladder has no conspicuous wall mass. The prostate is appropriate in size for age, with preserved zonal anatomy and no conspicuous focal lesion on this routine pelvic protocol. Seminal vesicles are symmetric. No pelvic lymphadenopathy, free fluid, or suspicious marrow lesion is identified.

Technique: Noncontrast CT of the chest was performed with axial images and multiplanar reformations.

Comparison: None available.

Findings: The trachea and central bronchi are patent. No focal consolidation, significant ground-glass opacity, suspicious pulmonary nodule, or mass is identified. No pleural effusion or pneumothorax. No pathologically enlarged mediastinal or hilar lymph node is identified. Heart size is within normal limits. No pericardial effusion. The thoracic aorta is normal in caliber. No significant abnormality is identified in the visualized upper abdomen. No acute or destructive osseous abnormality is identified.

Impression: No significant intrathoracic abnormality on noncontrast chest CT.

Technique: Noncontrast head CT was performed with axial images and multiplanar reformations.

Comparison: None available.

Findings: No acute intracranial hemorrhage is identified. Gray-white matter differentiation is preserved. No focal parenchymal attenuation abnormality is identified. No mass effect or midline shift. The ventricles and cortical sulci are appropriate for age. The basal cisterns are patent. No acute calvarial fracture is identified. The visualized paranasal sinuses and mastoid air cells show no significant abnormality.

Impression: No acute intracranial abnormality.