Left testis measures 4.7 x 1.9 x 2.8 cm. Echotexture is uniform.

The example sentence is an incomplete description. By ultrasound, organs have size, contour, echogenicity and echotexture.

Without stating “normal size”, the author assumes the report reader knows that “4.7 x 1.9 x 2.8 cm” falls in the normal size range.

No comment is made about contour; an organ can have normal size but abnormal contour.

“Echotexture is uniform” is okay but more simply stated “uniform texture”. Also, it is possible to have uniform echotexture, but abnormal echogenicity. For example a fatty liver shows homogeneous (uniform) echotexture, but abnormally increased echogenicity.

“Testicle” is a better word than “testis” from the standpoint of plain English. More people are clear about the meaning of testicle than testis. As more patient have access to radiology reports we can reduce confusion and eliminate unnecessary questions.

Possible rewrite of the finding: The left testicle has normal size (4.7 x 1.9 x 2.8 cm), contour, echogenicity and texture.

The impression of this finding would be: Normal testicle.

“Atherosclerotic calcifications involving the coronary arteries. And atherosclerotic calcifications also noted involving the thoracic aorta.”

(Never mind the glaring “typo”, Coble.)

Neither of the example sentences reports severity. If a finding is important enough to report, then it’s important enough to characterize. If it’s not important enough to characterize, reporting it isn’t likely to be helpful. (What is the ordering physician going to do about “atherosclerotic calcifications also noted involving the thoracic aorta”?)

Writing “atherosclerotic calcifications” in successive sentences makes more work for the reader. Frequently such sentences can be combined. For example: Atherosclerotic calcifications involving the coronary arteries and thoracic aorta.

It’s clear the interpreting physician made and reported the first observation, and then made and reported the next finding. It’s an easy way to dictate, but authors should try to make things easy for the reader not for themselves.

With regard to the phrase …involving the thoracic aorta:

It’s a chest CT. Just saying “aorta” is good enough. (If you are making an observation of the upper abdominal aorta on a chest CT, then say “upper abdominal aorta” or “suprarenal abdominal aorta”.  In the example sentence, the adjective “thoracic” is a waste of syllables. Use those syllables for something more informative like “ascending” or “descending”. Or “mild”, “moderate”, “severe”.

Also, i don’t think i ever see arterial calcification in the chest that isn’t atherosclerotic, We can safely eliminate this 6-syllable adjective in most cases.

-don’t need to say “noted” since the radiology report is a note.

-“involving” (used in both of the example sentences) can usually be avoided. For example: “Atherosclerotic aortic calcifications” instead of “Atherosclerotic calcifications involving the aorta.”

Potential rewrite of the example sentences: Mildly calcified coronary arteries and ascending aorta.

Compared to the example sentences the edited version is shorter, easier to read, and more complete (includes severity and location).

“Relocation of the left proximal femoral component with regard to the acetablular component.”

1. Relocate means “move to a new place”; it is not the opposite of dislocate. Reduced is the accepted word to describe this finding.  Proximal is an unnecessary adjective since the whole femur is “relocated” when the dislocation is reduced.

2. In what “regard” is a proximal femoral component relocated other than to the acetablular component?

Possible rewrite: “Reduced prosthetic hip dislocation since the prior exam.”

“Extensive pancreatic bed calcifications compatible with chronic pancreatitis.”

The example sentence is ambiguous and imprecise. The author means “extensive pancreatic calcifications compatible with chronic pancreatitis.”

The “pancreatic bed” is an informal description of the retroperitoneal space containing the pancreas. (Specifically, the pancreas lies in the anterior pararenal space.)

While it is true that calcifications in the pancreas are also in the “pancreatic bed”,  it is not necessarily true that calcifications in the pancreatic bed are in the pancreas.  There is no reason to hedge; say they are in the pancreas.

Suggested rewrite: “Numerous pancreatic calcifications most likely representing chronic pancreatitis.”

1. The common definition of extensive is “large in size or amount”. Extensive calcifications could mean the calcifications are large; which they are not.  I used numerous since its common definition (existing in large numbers) is an unambiguous description of the finding.

2. In the example “compatible with chronic pancreatitis” isn’t bad, but the finding is also “compatible with” other diseases. I rephrased this to give a statistical concept that chronic pancreatitis is the most likely of all possible causes. Since this is an incidental finding i would not report a differential diagnosis.

http://radiopaedia.org/articles/pancreatic-calcifications-2

“No focal suspicious intrahepatic lesion.”

This is radiologist code-speak for normal liver.

In the context of the example sentence “no focal” also means “no multifocal”, “no diffuse”, “no infiltrating”. In fact, “no focal” means none. We could change the sentence to “No suspicious intrahepatic lesion” without changing its intent.

What does suspicious mean in the example sentence? Does it mean there are lesions in the liver, just not suspicious ones? Probably not since it would be appropriate for the radiologist to have described such lesions (cyst, hemangioma etc.) before concluding they were not suspicious. The word suspicious can be removed leaving “No intrahepatic lesion.”

What does the prefix “intra-” add? Is an “intrahepatic lesion” different than an “hepatic lesion”? It is not. The prefix adds two more syllables but no more meaning.

Possible revision:“No liver lesions”.  (Assuming the clinical question required a pertinent negative statement regarding the liver.) If the clinical information for the exam indicated no apparent concern for liver disease ( ie. “Left lower quadrant pain, rule-out diverticulitis”), then simply stating “Normal liver” would be appropriate.

The original example sentence had a Flesch-Kincaid reading level of 17.0 and a NEGATIVE reading ease score! The suggested revision has a 5.2 grade reading level and reading ease of 63.

example:

rewrite:

1. Stable disease*. No metabolically active tumor.

2. Mild ascites, decreased since mm/dd/yy. Decreased omental nodules.

3. Likely inflammatory FDG-avid hilar lymph nodes. Tiny, ametabolic pulmonary and subcutaneous nodules are indeterminate. (any recommendations???)

4. Mild, stable slenomegaly.

5. Stable left inguinal hernia and left hydrocele as described.

*could be partial response depending on criteria

Example: “There is no significant FDG avidity in the left breast to suggest residual FDG avid malignancy. There is no evidence of abnormal FDG uptake or lymphadenopathy in the left axilla to suggest FDG avid lymphadenopathy.”

Flesch-Kincaid reading level  =  13.8; reading ease score = 27.1  

Possible rewrite: “No significant abnormal FDG activity in the left breast or axilla. No enlarged lymph nodes.”

Flesch-Kincaid reading level = 7.7; reading ease score = 52.5

The example mixes findings and impressions making the sentence more complicated by duplicating information that should be in the report impression, ex.”Impression: No FDG avid residual, recurrent or metastatic tumor.” Or more simply “No FDG avid tumor.”

Example: “On bone windows, atherosclerotic calcifications are present at the skull base.”

It’s not necessary to report “on bone windows.” It adds no relevant information regarding athersclerotic calcification. It’s analogous to us getting the following history for a chest radiograph: “On auscultation left lower lobe rales are present.” It doesn’t matter how the physical finding was made. It’s only the finding itself that matters. The other information is extraneous.

The words “are present” do not carry useful information and should be omitted from the example. With these proposed edits the example would read “Atherosclerotic calcifications at the skull base.”

“At the skull base” is a vague description. Furthermore, the example sentence gives no idea of severity.  If I felt compelled to report vascular calcification in this region, I’d say where and how bad:  “Mildly calcified distal cervical internal carotid arteries.”

Example: “On bone windows, atherosclerotic calcifications are present at the skull base.”

Possible rewrite: “Mildly calcified distal cervical ICAs.”

Example: “Adjacent to the right thyroid gland in the cervical lymph node chain there is an elongated lymph node, measuring 3.5 x 1.3 x 0.7 cm.”

There is only 1 thyroid gland. There is no right thyroid gland or left thyroid gland. It’s not like right and left kidneys. There are right and left lobes of the thyroid gland. There is no reason to say anything other than “lobe”. It’s more accurate and shorter than “gland”.

A lymph node “adjacent to the right thyroid gland” will only be in the cervical lymph node chain. As such, the words “in the cervical lymph node chain” don’t impart any useful information.

The word “elongated” is subjective and ambiguous. Does it mean the node is abnormal? Giving  three-dimensions allows the reader to understand the node’s configuration. (Obviously some additional comments regarding morphology such as “echogenic hilum” would be needed for complete description.)

Example: “Adjacent  to the right thyroid gland in the cervical
lymph node chain there is an elongated lymph node, measuring 3.5 x 1.3 x
0.7 cm.”

Possible rewrite: “3.5 x 1.3 x 0.7 cm lymph node adjacent to the right thyroid lobe.”

The proposed edit takes the sentence from a Flesch-Kincaid 12.5 grade level down to 7.5, and improves the readability score from 49.4 to 65.7.

“The bony calvaria is intact.”