一些不當(dāng)用詞:
• Significant The word “significant” in scientific writing is usually used only in the context of statistical significance. In radiology reporting “no significant abnormality or change” is acceptable but overused.
Aphthous ulcer: An aphtha is already an ulcer, “a small ulcer on a mucous membrane” .
• Atypical, asymmetric, adynamic: The meaning of these words will be reversed if they are transcribed “a typical.” Nontypical is preferable.
• Bony or boney: The noun “bone” has evolved into an adjective. Osseous is preferable.
• Cardiac silhouette: This term, rather than simply “heart,” is appropriate only in the 1% of chest radiographs in which a pericardial effusion is suspected.
• Cardiothymic silhouette: This pediatric term is inappropriate in adults.
• COPD: Chronic obstructive pulmonary disease is a clinical spectrum of diagnoses that includes chronic bronchitis. Radiographs
reveal emphysema, a far more specific and important entity.
• Dye: Contrast agents have no color. The only rationale for the misuse of this term is that dye has only three letters and is a single syllable.
• Echolucent and sonolucent: These terms are throwbacks to “radiolucent,” whatever that is. “Anechoic” or “hypoechoic” are more acceptable.
• Epicenter: This term, meaning over the center, is applicable to earthquakes.
• Flat plate of abdomen: Most of us would not recognize an antique glass photographic plate. This term is on a par with KUB (kidneys–ureters–bladder).
• Good, satisfactory, acceptable: These judgments are in the eye of the beholder.
• Hip fracture: Joints dislocate and bones fracture.
• Infiltrate: This is an acceptable pathology term, but its use will unduly disturb most of your pulmonary imaging colleagues.
• Inhomogeneous: Do you mean heterogeneous?
• IVP: Pyelo means pelvis. The acronym IVP originated because early contrast agents often opacified only the renal pelvis. The acronyms
EU or IVU (excretory or intravenous urogram) are preferable. If you perform many of these obsolete examinations, you and your referring clinicians might benefit from additional continuing medical education.
• KUB: This term originated with urologists. Radiologists need broader horizons when perusing abdominal radiographs.
• Lung markings: This terminology is controversial, but the use of “l(fā)ung fields” is inexcusable.
• Mild: Mild (or severe) are functional or physiologic adjectives. “Slight” is the preferable scientific term for size or quantity. Slight cardiomegaly and slight congestion may reflect mild CHF.
• Neer and Judet views: Radiologists were obtaining oblique images of the shoulder and pelvis long before Neer and Judet made their important contributions.醫(yī)學(xué)全在線www.med126.com
• Obese: This is an acceptable scientific word but it has pejorative connotations, and patients read their reports. Preferable language might be large size or large body habitus.
• Osteoporosis and osteopenia: The use of these qualitative terms to describe radiographs has been preempted by quantitative T scores greater than 2.5 and 1.0, respectively. I now use the term “demineralization”.
• Permits and permission: Physicians should not request permission to perform an examination. The patient does the requesting and should sign an informed consent rather than a permit. Take note when physicians and lawyers agree.
• Plain and conventional radiograph: I agree with Rogers that “radiograph” without the modifiers is preferable.
• Poor inspiration or inspiratory effort: A poor effort is subjective, possibly disparaging, and often incorrect. High diaphragms usually reflect body habitus or decreased lung compliance.
• Portable radiograph: Portable means capable of being carried. Radiographs are portable, but X-ray machines are not. The term “bedside” is also imperfect but preferable.
• Pulmonary edema: This term is etiologically less specific than CHF. It may also confuse clinicians who associate it with symptomatically severe CHF.
• Reading examinations: Books are read and images interpreted. Likewise, images “show,” “reveal,” and possibly “detect” but only thinkers, like the radiologist, can “demonstrate.”
• Shadow: Shadows are the lowest level of interpretation. I associate them with electromagnetic waves in the visible spectrum.
• Shoulder separation: Acromioclavicular joints separate and glenohumeral joints dislocate.
• Status post: How does status post differ from post? Is one status post surgery for life, or is there a time limit?
• X ray or roentgenogram: These terms for a radiograph are incorrect or archaic.
Impression (Conclusion)
不要使用“Diagnosis” ：“Impression” or “Conclusion” is preferable to “Diagnosis” because a diagnosis is more specific and thereby encourages radiologists to hedge. Others disagree and alternative words include summary, opinion, interpretation, and reading. When there is a 98% chance that findings are normal, or cancer, or fracture, or smallbowel obstruction (SBO), omit the hedges. After all, it is only an impression. The statement that no fracture is seen or identified, implying that a fracture may have been missed, is appropriate for radiographs of ribs or externally rotated hips in osteoporotic women. It is inappropriate for radiographs of long bones in young individuals.
Impressions are an excellent gauge of the common sense and clinical judgment of the radiologist. Separating the important from the incidental often takes time and thought. Keep it short. If readers want details they can refer to the descriptive section of the report. Impression: “Pneumonia” is preferable to repeating that it is a “patchy posterior segment left upper lobe pneumonia.”醫(yī)學(xué)全在線www.med126.com
“Impressions” are superfluous when reports will never be read.
最重要的FIRST：Do not number diagnoses and place each on a separate line or paragraph. This practice lengthens reports and encourages listing of non-pertinent findings. Tailor the “Impression” by addressing the clinical problem. Urgent or important findings should be described first. This advice is particularly applicable to lengthy reports and impressions that are unlikely to be completely read.
Do not repeat observations in the “Impression.” This admonition is difficult when the diagnosis is uncertain. However, stating that there is an abnormality of uncertain cause or significance is preferable to iterating previous descriptions.
不重復(fù)檢查手段：Do not repeat the name of the examination in the “Impression.” “Normal chest radiograph,” “normal CT of the abdomen” (if there is such a thing), and “no mammographic evidence of malignancy” are repetitious.
和臨床醫(yī)生溝通：The use of the first person adds a personal touch, particularly when there is equivocation: “I doubt this is of clinical significance” or “I would be happy to discuss this with you.” Radiologists make too many recommendations, particularly in patients about whom we have little clinical history. These recommendations are often not helpful, are sometimes inappropriate, and are occasionally simply wrong. When the recommendation is obvious, it may be resented: most clinicians are not interested in our suggestions when the tube is in a bronchus or there is a new lung mass. Conversely, insecure clinicians may feel medicolegal pressure to act on our suggestions for additional imaging.
The terms “clinical correlation needed” and “if clinically indicated” are overused. They sometimes reflect defensive posturing by the radiologist.
State in the report that findings were conveyed to the referring physician. Written documentation is also necessary if a preliminary report, perhaps by a resident, undergoes substantive change before finalization.
