Suspect varicocele left side.

without Valsalva

with Valsalva

Saying “suspect varicocele” would cause uncertainty for the report reader. A consultant would have no choice but to request images to decide if there is or isn’t a varicocele.

Unnecessary hedges like this devalue radiologists. Why pay a radiologist when the urologist will look at the same images and say “there is a varicocele”?

Rewrite: Left sided varicocele.

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.