Author Archives: Hyperlucent

Interval Change

“IMPRESSION: Expected postsurgical change of the distal fibula and medial malleolus ORIF without significant interval change when compared to the prior study dated 07/23/13.”

The word “interval” is redundant and should be omitted. The time interval is defined by the current and comparison exam dates and doesn’t need to be referenced by name.

“…when compared to the prior study dated 07/23/13” is unnecessarily verbose. Writing “…since the 07/23/13 exam” gives the same information 3 reading-levels less.

The word “exam” is implicit in the comparison date and can be omitted. The phrase could be shortened to just the date “…since 07/23/13.”

Rewritten example:

“IMPRESSION: Expected postsurgical appearance of distal fibula and medial malleolus ORIF not significantly changed since 07/23/13.”

No abnormal FDG activity

Example: “HEAD/NECK: No abnormal FDG activity is seen. Normal physiologic activity is seen in the base of the brain. No significant adenopathy in the neck.”

line by line analysis:

“No abnormal FDG activity is seen.”
“is seen” in this case is a hedge that translates “there may be abnormal FDG activity, but I don’t see it.” Say “No abnormal FDG activity.”
“No abnormal” is a double negative that means “normal”.
Could say; “Normal FDG activity” or “Normal metabolism.”

“Normal physiologic activity is seen in the base of the brain.”
The words “is seen” can be safely removed.
This negative finding is an impertinent negative unless the clinical indication questions CNS disease. It’s inconsistent to report normal brain activity unless you are going to report all other organ specific physiologic activity; which is unnecessary. If the report structure is modular and includes a section for HEAD/NECK, the first sentence “No abnormal FDG activity” excludes abnormality at the base of the brain and obviates the need for the second sentence.

“No significant adenopathy in the neck.”
This sentence says “there is adenopathy, but it’s not significant.”
(adenopathy is a misnomer; adeno- means gland, and lymph nodes are not glands.)
As frequently used, adenopathy means “diseased nodes”. With this understanding any adenopathy is significant. I’d say “No enlarged lymph nodes.”

Example: “HEAD/NECK: No abnormal FDG activity is seen. Normal
physiologic activity is seen in the base of the brain. No significant
adenopathy in the neck.”

Possible rewrite:  “HEAD/NECK: Normal FDG activity. No enlarged lymph nodes.”

prominent vasculature

“IMPRESSION: There is prominence of the vasculature without frank pulmonary edema.”

“Prominence of the vasculature” is an imprecise description of a radiographic finding, not a diagnostic impression.
 
The example sentence can be interpreted as either normal or abnormal. If there is uncertaintly I think it’s better to be upfront about it: “Early pulmonary edema is possible.” 

Does “prominent” mean normal or abnormal? Cephalized, redistributed flow to the upper lobes is a well-known radiographic finding usually thought to result from early lower lobe intersitial edema. If by “prominent” the author means “cephalized”, then pulmonary edema is likely in progress.

If “frank pulmonary edema” is intended to mean alveolar edema, it’s more precise to say alveolar or airspace edema, since “pulmonary edema” encompasses both tissue (interstitial) and airspace (alveolar) edema.

Considering edema distribution, heart size/contour, mediastinal width, pleural and subpleural spaces I usually try to give my impression as to cardiogenic or noncardiogenic edema. I’d rewrite the examples sentence something like: “Possibly early cardiogenic interstitial edema.”  The implication being that clinical correlation for dyspnea/orthopnea etc. is needed. I don’t feel the need to say “clinical correlation required…” in this circumstance, particularly if the provided history is “SOB”.

 

normal in size

“The cardiac silhouette is normal in size.”

Another example of more words saying less. The cardiac silhouette, like all radiographic opacities, has properties other than size. The example sentence leaves the reader to assume the other features (location, contour, margins, attenuation) are normal. 
Simply saying “The cardiac silhouette is normal” indicates that all observable features of the structure are within normal limits, and is more concise.

increased hypoattenuation

“There is an area of increased hypoattenuation in the right parietal lobe.”

“increased hypoattenuation” sounds awkward to me. Similar to saying “increased decreased attenuation”.

This example sentence was not made in reference to a prior study, so “There is an area of hypoattenuation in the right parietal lobe” would suffice.

If I was trying to describe a hypoattenuating area that had become even lower in attenuation, I’d say “more hypoattenuating”. Something like “Left parietal lesion is more hypoattenuating than on the prior exam.”



mid lung zone

“The nodule in the right mid lung zone no longer exhibits increased metabolic activity. That has decreased in size currently measuring approximately 11 x 4 mm compared to 16 x 10 mm previously.”

“right mid lung zone” is not an accurate localization on a PET-CT. It is impossible to visualize the lesion from this description.
I have to make up an anatomic location for the purpose of rewriting this sentence:
”11 x 4 mm posterolateral right upper lobe nodule is no longer hypermetabolic, and decreased from the previous 16 x 10 mm.



erosive process

“Mild soft tissue swelling without erosive process identified in the hand or wrist.”

-omit “identified”
Presuming the clinical question was something like “pain, r/o rheumatoid arthritis”, I’d probably say something like “Mild soft tissue swelling but no periarticular erosions.” 

 I don’t think “without erosive process…” is as direct as “but no periarticular erosions…”



first digit

“Lucency through the base of the first digit distal phalanx which raises the possibility a minimally displaced fracture, as above.”

The phrase “which raises the possibility” says no more than “, possibly”. 
A hand surgeon taught me to just say thumb, index, middle, ring and small (or little) to describe the fingers. There is never any confusion and it’s no harder. No advice for the toes other than “great” or “hallux”, then second, third etc. 
It’s plausible that for such simple findings and diagnosis the impression could contain both. The example sentence was just a report impression. The radiographic findings of a luceny were well-described in the “findings” section and didn’t need to be repeated. I think it’s better said:  “Possible nondisplaced fracture base of the distal thumb phalanx, as above.” 



somewhat indeterminate

“Calcification makes this lesion somewhat indeterminate.”

Is “somewhat indeterminate” more or less definitive than “really indeterminate”? Just say “indeterminate”.

rewritten: “Calcification makes this lesion indeterminate.”