“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.”
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fibrotic change
fibrotic change = fibrosis
Don’t use two words when one word will do.
“Fibrotic change” isn’t a description. Reticular or linear opacities with honeycombing etc. describe the radiographic findings.
aneurysmal
“Aneurysmal dilatation of the acending aorta.”
Aneurysm means dilation. “Aneurysmal dilatation” is redundant, the equivalent of saying “dilated dilatation.”
rewritten: “Ascending aortic aneurysm.” or “Dilated ascending aorta.”
atelectatic change
Turning the noun atelectasis into the adjective “atelectatic” results in use of two words instead of one.
“Atelectatic change” says nothing more useful than “atelectasis”.
If it’s a description that’s needed then “subsegmental opacity with volume loss” etc. is a better description of atelectasis. “Atelectatic change” isn’t a description.
poor effort
“Enlarged cardiac silhouette may be secondary to the patient’s poor respiratory effort as well as portable AP technique.”
Respiration is the act of breathing and includes both inspiration and expiration. It would be better to say “inspiratory effort.” However, it’s not possible to judge a patient’s effort by radiography. It could be the patient was in pain and made a great, albeit unsuccessful, effort.
I’d say “Enlarged cardiac silhouette accenuated by hypoinflation.”
lungs themselves
“The lungs themselves are clear.”
omit “themselves”:
“The lungs are clear.”
on the left
“Abutting the submandibular gland on the left.”
Say “Abutting the left submandibular gland” It’s shorter and unambiguous. The example sentence could conceivably mean abutting the left side of either submandibular gland.
again noted to be
“There is again noted to be stable persistent symmetric increased activity throughout the thyroid bed.”
“There is again noted to be” – delete
“stable persistent” – if something is stable it HAS to be persistent; just say stable
“throughout the thyroid bed” – presumably this means the thyroid gland. But open to interpretation
rewritten version: “Stable, diffusely hypermetabolic thyroid gland.”
at the present time
“At the present time there is no evidence of pulmonary embolus.
I have no idea how saying “At the present time” is supposed to benefit the clinician more than just “No evidence of pulmonary embolus.”
The word “evidence” is overused and most often incorrectly, but I’d let it go in this instance. Although we usually see emboli, it’s conceivable we could infer their presence based on classic evidence such as pulmonary infarct, oligemia or right heart strain.
I say “No embolic lung disase” but I think “No evidence of pulmonary embolus” is okay.
radiographically evident
“No radiographically evident cardiopulmonary disease.”
I don’t believe it’s possible to diagnose something on a radiograph that has no radiographically evident findings. No do I believe we can be reasonably held to the standard of seeing something that cannot be seen.
It’s doubtful this wording would be an effective medicolegal hedge. If you say “not radiographically evident”, but 100 other people see a pulmonary nodule, then it is radiographically evident regardless of your statement to the contrary. Would be in no worse a defense position saying “No cardiopulmonary disease” or “Normal study” and missing the same nodule.