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Signalment, Projections and Quality:
The radiology report should state the signalment of the patient, ie skeletally mature or immature, male or female, then list the projections provided, including any techniques used, for example contrast studies.
A comment should then be made on radiographic technique and quality including a comment on: positioning, exposure and collimation and state if any artefacts are present. A method for remembering these aspects is the PLACE system:
P Positioning
L Labelling ie is the film correctly labelled with patient details and left and right labels, prior to processing
A Artefacts- are any present, if so list
C Collimation
E Exposure
Radiographic Description:
In this section you describe your radiographic findings. Radiologic findings include consideration of the Roentgen signs such as size, shape, opacity, number and position of organs. Avoid using the term "there appears to be" if something actually is. The radiographic signs must be described. For the radiographs of the distal radius below in the exam situation it is insufficient to say for example "There is an aggressive bone lesion within the distal radius" without describing the soft tissue swelling, the permeative and moth eaten lysis, cortical destruction, irregular periosteal new bone production and Codman's triangle. The conclusion that this is an aggressive bone lesion is left until the Radiographic Interpretation section.
Radiographic Interpretation or Conclusion:
This is where you state the interpretation of your findings ie: an aggressive bone lesion within the distal radius, This is not the place to introduce new information; it is a summary of your findings. You must provide an interpretation of each abnormality you described in your description.
Differential diagnoses:
List the differential diagnoses for each abnormality in rank order of most to least likely, for example primary bone neoplasia is most likely such as osteosarcoma, chondrosarcoma; fibrosarcoma; haemangiosarcoma, less likely osteomyelitis.
Further recommendations:
The recommendations depend on the case being discussed, it may involve further imaging or sampling. For example the aggressive bone lesion within the distal radius further imaging is recommended: a three view thorax to assess for the presence of pulmonary metastases, and further tests: a bone biopsy for the definitive diagnosis. However in the radiology membership exam the examiners only require recommendations for further imaging.
