英文版影像报告书写.docx

英文版影像报告书写.docx

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英文版影像报告书写

英文版影像报告书写

1.头颅骨质未见异常

Theshapeandthesizeoftheskullarenormal。

Theinnerandoutertables，andthediploeofthecranialvaultareunremarkable，onthelateralview，thesizes，theshapeandthedensityofthesellaturcicaarenothingremarkable。

Impression：

plainfilmsoftheheadarenormal.

2.头颅正常

APandlateralviewsoftheskullaresubmitted.Thecavariumhasnormalconfigurationandappearance.Thereisnoevidenceoffracture.Thesofttissuesarenormal.

Impression:

Normalskull.

3.鼻旁窦炎症

Thereisgeneralizedhazinessofthefrontal,ethmoidandbilateralmaxillarysinuses.Findingsareconsistentwithsinusitis.

Impression:

Frontal,（额窦）ethmoid（筛）andmaxillary（上颌）sinusitis.

4.右膝关节正常

Thebonesandjointsoftherightkneearenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Thereisnojointeffusion.

Impression:

Normalrightknee.

5.右膝退变

Thebonesandjointsoftherightkneearenormal.Milddegenerativechangesofthekneejointispresent.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.Thereisnojointeffusion.

Impression:

MildDJDofkneejoint。

6.左小腿蜂窝炎，（软组织肿胀，无骨髓炎）

Thereismilddegreeofsofttissueswelling10.9cmattheproximalanteriorleg.Thereisnoevidenceofadjacentboneabnormality.Thereisnoevidenceofperiostealreaction.Thefibularbonehasnormalconfigurationandappearance.

Impression:

Thereisafocal10.9cmlengthsofttissueswellingattheproximalanteriorlegadjacenttothetibia.Thetibialbonehasnormalconfigurationwithnoevidenceofosteomyelitis.Findingsareconsistentwithlocalizedcellulitis.

7.右侧胫骨石膏固定中，位置可，和老片比较相似

Therightlegisinaplastercast.Thereisobliquefractureoftherightmidtibialshaft.Thereismildcallousformationacrossthefractureline.Thebonefragnmentsareinproperalignment.Comparisonwithpreviouseximinationof4/19/2006revealsnosignificantintervalchange.

Impression:

S/Pfractureoftherightmidtibialshaft.Callousformationispresentacrossthefractureline.

Thereisnointervalchangefrompreviousstudyof4/19/2006.

8.右足正斜位正常

Thebonesandjointsoftherightforefootarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.

Impression:

Normalrightforefoot.

9.正常左踝正侧位

APandlateralviewsoftheleftanklewereobtained.Thebonesandjointsoftheanklearenormal.Thereisnofracture.

Impression:

Normalleftankle.

10.右侧足背距骨和舟状骨之间退变

Thebonesandjointsoftherightforefootarenormal.Milddegenerativechangesofthetalo-navicularjointispresent.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.

Impression:

Normalrightforefoot.MildDJDoftalo-naviculatjoint.

11.双侧足背斜位，拇外翻

Thereismilddegreeofhalluxvalgusdeformitiesofthebothfeetrightandleft.Thebonesandjointsoftherestofthefeetareunremarkable.Softtissuesarewithinnormallimits.

Impression:

1.Mildrighthalluxvalgusdeformities.

Thebonesandjointsofbilateralelbowsarenormal.Thesofttissuesarenormal.Thereisnoevidenceoffractureorsubluxation.

Impression:

Normalelbows.

13.右侧拇指正常

Thebonesandjointsoftherightthumbarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.

Impression:

Normalrightthumb.

14.右肩关节正位正常

Thebonesandjointsoftherightshoulderarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.

Impression:

Normalrightshoulder.

15.右腕正侧位正常

Thebonesandjointsoftherightwristarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.

Impression:

Normalrightwrist.

16.双侧腕关节（右侧正常，左侧横行骨折，未移位）

Thereisatransversenondisplacedfractureoftheleftdistalradialmetaphysisregion.Theleftwristisnormalinconfigurationandappearance.Therightdistalforearmandrightwristarenormalinappearance.Softtissuesarewithinnormallimits.

Impression:

Transversenondisplacedfractureoftheleftdistalradialmetaphysis.Rightdistalforearmandwristarenormal.

Thebonesandjointsofthelefthandarenormal.Thereisnoevidenceoffractureorsubluxation.Thesofttissuesarenormal.

Impression:

Normallefthand.

18.正常锁骨片（左）

Theleftclaviclehasnormalconfigurationandappearance.Thesofttissuesoftheneckabovetheclavicleisnormlainappearance.Scapularandleftshoulderjointarewithinnormallimits.

Noevidenceofsofttissuemassisdemonstrated.Impression:

Normalleftclavicle.

19.左锁骨及肩胛骨

APviewsoftheleftshoulderandscapularevealnormalbonesandjoints.Thereisnoevidenceoffractureorboneabnormality.Thesofttissuesarenormal.

Impression:

Normalleftshoulderandscapula.

20.腹部立卧位正常片

Supineanduprightviewsoftheabdomenaresubmitted.Thebowelgaspatternisnormal.Thereisnoevidenceofintestinalobstruction.Thereisnoevidenceofabnormalcalcificationsoverlyingthekidneysorthepelvis.Theosseousstructuresarenormal.

Impression:

Normalabdomen.

21.腹部立位正常：

Thebowelgaspatternisnormal.Thereisnoevidenceofabnormalcalcifications.Theosseousstructuresarenormal.

Impression:

Normalabdomen.

22.腹部立位大便

APerectviewoftheabdomenrevealfecesfilledcolon.Thereisnoevidenceofabdominalmassorcalcifications.Theosseousstructuresarenormal.

Impression:

Fecesimpactedcolon.

23.颈椎增生性改变

Thealignmentofcervicalvertebraisnormal.Curveofthecervicalvertebraexist（disappear）.NarrowingoftheintervertebalspacebetweenC？

andc？

isfound.Slightosteophytesarerevealedattheposterior/anteriorofC？

－c？

.Thereisnofractureordislocation.

24.胸椎增生性改变

Thealignmentofthoracicvertebraisnormal.Curveofthecervicalvertebraexist（disappear）.Narrowingoftheintervertebalspacebetweent？

andt？

isfound.Slightosteophytesarerevealedattheposterior/anterioroft？

－t？

.Thereisnofractureordislocation.

Impression:

Hyperplasychangesofthethoracicvertebra.

25.颈椎正常

Thealignmentofcervicalvertebraisnormal.Curveofthecervicalvertebraexist.Theintervertebalspacebetweenthecervicalvertebraisnormal.Noosteophytesarerevealedatthecervicalvertebrabodies.

Impression:

Normalofthecervicalvertebra.

26.胸椎正常

Thealignmentofthoracicvertebraeisnormal.Curveofthethoracicvertebraeexist.Theintervertebalspacebetweenthethoracicvertebraisnormal.Noosteophytesarerevealedatthethoracicvertebrabodies.

Impression:

Normalofthethoracicvertebra.

27.腰椎正常

Thealignmentoflumbarvertebraeisnormal.Curveofthelumbarvertebraeexist.Theintervertebalspacebetweenthelumbarvertebraisnormal.Noosteophytesarerevealedatthelumbarvertebrabodies.

Impression:

Normalofthelumbarvertebra.

28.颈椎退行性变

Thealignmentofcervicalvertebraisnormal.Curveofthecervicalvertebradisappear.NarrowingoftheintervertebalspacebetweenC？

andc？

斜位片有椎间孔狭窄时：

＋Thesecauseminimalnarrowingoftheintervertebralforamina.Severeosteophytesarerevealedattheposterior/anteriorofC？

－c？

Thereisnofractureordislocation.

Impression:

Degenerativeofthecervicalvertebra.

29.腰椎退行性变

Thealignmentoflumbarvertebraisnormal.Curveofthelumbarvertebradisappear.Narrowingoftheintervertebalspacebetweenl？

andl？

斜位片有椎间孔狭窄时：

＋Thesecauseminimalnarrowingoftheintervertebralforamina.Severeosteophytesarerevealedattheposterior/anteriorofl？

－l？

Thereisnofractureordislocation.

Impression:

Degenerativeofthelumbarvertebra.

30.胸片正侧位正常

PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.

Impression:

NormalChest

31.胸片正位正常

PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.

Thereisnoevidenceoflungmassorinfiltrate.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.

Impression:

NormalChest

32.胸片有钙化点无其它肺部疾病。

PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.Thereisnoevidenceoflungmassorinfiltrate.Asmallcalcifiedatthetopoftherightlung.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.

Impression:

Smallcalcifiedatthetopoftherightlung.Noacutelungdisease.

33.胸部小结节。

PAviewofthechestwasobtained.Bothlungfieldsarewellexpanded.

Thereisasmalllungnodule3mmsizeattherightmidlung.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.

Impression:

3mmnoduleatrightmidlung.SuggestcomparisonwitholdCXRtoensurestability,otherwisesuggestCTchest.

34.两肺纹理增多，未见明显感染之征象。

APviewofthechestwasobtained.Bothlungfieldsarewellexpanded.

Thereisnoevidenceoflungmassorinfiltrate.Mildincreaseoflungmarkingsarepresent.Bilateralapicesarenormal.Bilateralpleuralspacesarenormal.Thecardiaccontourisnormal.Themediastinumandbilateralhilaarenormal.

Impression:

Mildincreaseoflungmarkings.Nofocalinfiltrateisseen.

35.胸片侧位，肋骨骨折

Bilaterallungsarenormal.Thehearthasnormalsizeandcontour.Themediastinumisnormal.Thereisafractureofright7thaxillaryrib.

Impression:

1.Lungsarenormal.2.Fractureoftheright7thaxillaryrib.

36.胸部正侧位（右隔抬高，原因待查）

PAandlateralviewsofthechestwereobtained.Bothlungfieldsarewellexpanded