英文版影像报告书写.docx

1、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The shape and the size of the skull are normal。The inner and outer tables，and the diploe of the cranial vault are unremarkable，on the lateral view ，the sizes，the shape and the density of the sella turcica are nothing remarkable。Impression：plain films of the head are norm

2、al.2.头颅正常AP and lateral views of the skull are submitted. The cavarium has normal configuration and appearance. There is no evidence of fracture. The soft tissues are normal.Impression: Normal skull.3.鼻旁窦炎症There is generalized haziness of the frontal, ethmoid and bilateral maxillary sinuses. Finding

3、s are consistent with sinusitis.Impression: Frontal,（额窦）ethmoid（筛）and maxillary （上颌）sinusitis.4. 右膝关节正常The bones and joints of the right knee are normal. There is no evidence of fracture or subluxation. The soft tissues are normal. There is no joint effusion.Impression: Normal right knee.5.右膝退变The b

4、ones and joints of the right knee are normal. Mild degenerative changes of the knee joint is present. There is no evidence of fracture or subluxation. The soft tissues are normal. There is no joint effusion.Impression: Mild DJD of knee joint。6.左小腿蜂窝炎，（软组织肿胀，无骨髓炎）There is mild degree of soft tissue s

5、welling 10.9cm at the proximal anterior leg. There is no evidence of adjacent bone abnormality. There is no evidence of periosteal reaction. The fibular bone has normal configuration and appearance.Impression: There is a focal 10.9cm length soft tissue swelling at the proximal anterior leg adjacent

6、to the tibia. The tibial bone has normal configuration with no evidence of osteomyelitis. Findings are consistent with localized cellulitis.7.右侧胫骨石膏固定中，位置可，和老片比较相似The right leg is in a plaster cast. There is oblique fracture of the right mid tibial shaft. There is mild callous formation across the f

7、racture line. The bone fragnments are in proper alignment. Comparison with previous eximination of 4/19/2006 reveals no significant interval change.Impression: S/P fracture of the right mid tibial shaft. Callous formation is present across the fracture line.There is no interval change from previous

8、study of 4/19/2006.8.右足正斜位正常The bones and joints of the right forefoot are normal. There is no evidence of fracture or subluxation. The soft tissues are normal.Impression: Normal right forefoot.9.正常左踝正侧位AP and lateral views of the left ankle were obtained. The bones and joints of the ankle are norma

9、l. There is no fracture.Impression: Normal left ankle.10.右侧足背距骨和舟状骨之间退变The bones and joints of the right fore foot are normal. Mild degenerative changes of the talo-navicular joint is present. There is no evidence of fracture or subluxation. The soft tissues are normal.Impression: Normal right fore

10、foot. Mild DJD of talo-naviculat joint.11.双侧足背斜位，拇外翻There is mild degree of hallux valgus deformities of the both feet right and left. The bones and joints of the rest of the feet are unremarkable. Soft tissues are within normal limits.Impression: 1. Mild right hallux valgus deformities.The bones an

11、d joints of bilateral elbows are normal. The soft tissues are normal. There is no evidence of fracture or subluxation.Impression: Normal elbows.13.右侧拇指正常The bones and joints of the right thumb are normal. There is no evidence of fracture or subluxation. The soft tissues are normal.Impression: Normal

12、 right thumb.14.右肩关节正位正常The bones and joints of the right shoulder are normal. There is no evidence of fracture or subluxation. The soft tissues are normal.Impression: Normal right shoulder.15.右腕正侧位正常The bones and joints of the right wrist are normal. There is no evidence of fracture or subluxation.

13、 The soft tissues are normal.Impression: Normal right wrist.16.双侧腕关节（右侧正常，左侧横行骨折，未移位）There is a transverse non displaced fracture of the left distal radial metaphysis region. The left wrist is normal in configuration and appearance. The right distal forearm and right wrist are normal in appearance.

14、Soft tissues are within normal limits.Impression: Transverse non displaced fracture of the left distal radial metaphysis. Right distal forearm and wrist are normal.The bones and joints of the left hand are normal. There is no evidence of fracture or subluxation. The soft tissues are normal.Impressio

15、n: Normal left hand.18.正常锁骨片（左）The left clavicle has normal configuration and appearance. The soft tissues of the neck above the clavicle is normla in appearance. Scapular and left shoulder joint are within normal limits.No evidence of soft tissue mass is demonstrated.Impression: Normal left clavicl

16、e.19.左锁骨及肩胛骨AP views of the left shoulder and scapula reveal normal bones and joints. There is no evidence of fracture or bone abnormality. The soft tissues are normal.Impression: Normal left shoulder and scapula.20.腹部立卧位正常片Supine and upright views of the abdomen are submitted. The bowel gas pattern

17、 is normal. There is no evidence of intestinal obstruction. There is no evidence of abnormal calcifications overlying the kidneys or the pelvis. The osseous structures are normal.Impression: Normal abdomen.21.腹部立位正常：The bowel gas pattern is normal. There is no evidence of abnormal calcifications. Th

18、e osseous structures are normal.Impression: Normal abdomen.22.腹部立位大便AP erect view of the abdomen reveal feces filled colon. There is no evidence of abdominal mass or calcifications. The osseous structures are normal.Impression: Feces impacted colon.23.颈椎增生性改变The alignment of cervical vertebra is nor

19、mal. Curve of the cervical vertebra exist（disappear）. Narrowing of the intervertebal space between C？ and c？ is found. Slight osteophytes are revealed at the posterior/anterior of C？c？. There is no fracture or dislocation.24.胸椎增生性改变The alignment of thoracic vertebra is normal. Curve of the cervical

20、vertebra exist（disappear）. Narrowing of the intervertebal space between t？ and t？ is found. Slight osteophytes are revealed at the posterior/anterior of t？t？. There is no fracture or dislocation.Impression: Hyperplasy changes of the thoracic vertebra.25.颈椎正常The alignment of cervical vertebra is norm

21、al. Curve of the cervical vertebra exist. The intervertebal space between the cervical vertebra is normal. No osteophytes are revealed at the cervical vertebra bodies.Impression: Normal of the cervical vertebra.26.胸椎正常The alignment of thoracic vertebrae is normal. Curve of the thoracic vertebrae exi

22、st. The intervertebal space between the thoracic vertebra is normal. No osteophytes are revealed at the thoracic vertebra bodies.Impression: Normal of the thoracic vertebra.27.腰椎正常The alignment of lumbar vertebrae is normal. Curve of the lumbar vertebrae exist. The intervertebal space between the lu

23、mbar vertebra is normal. No osteophytes are revealed at the lumbar vertebra bodies.Impression: Normal of the lumbar vertebra.28.颈椎退行性变The alignment of cervical vertebra is normal. Curve of the cervical vertebra disappear. Narrowing of the intervertebal space between C？ and c？斜位片有椎间孔狭窄时：These cause m

24、inimal narrowing of the intervertebral foramina. Severe osteophytes are revealed at the posterior/anterior of C？c？There is no fracture or dislocation.Impression: Degenerative of the cervical vertebra.29.腰椎退行性变The alignment of lumbar vertebra is normal. Curve of the lumbar vertebra disappear. Narrowi

25、ng of the intervertebal space between l？ and l？斜位片有椎间孔狭窄时：These cause minimal narrowing of the intervertebral foramina. Severe osteophytes are revealed at the posterior/anterior of l？l？There is no fracture or dislocation.Impression: Degenerative of the lumbar vertebra.30.胸片正侧位正常PA and lateral views

26、of the chest were obtained. Both lung fields are well expanded. There is no evidence of lung mass or infiltrate. Bilateral apices are normal. Bilateral pleural spaces are normal. The cardiac contour is normal. The mediastinum and bilateral hila are normal.Impression: Normal Chest31. 胸片正位正常PA view of

27、 the chest was obtained. Both lung fields are well expanded.There is no evidence of lung mass or infiltrate. Bilateral apices are normal. Bilateral pleural spaces are normal. The cardiac contour is normal. The mediastinum and bilateral hila are normal.Impression: Normal Chest32.胸片有钙化点无其它肺部疾病。PA view

28、 of the chest was obtained. Both lung fields are well expanded. There is no evidence of lung mass or infiltrate. A small calcified at the top of the right lung. Bilateral apices are normal. Bilateral pleural spaces are normal. The cardiac contour is normal. The mediastinum and bilateral hila are nor

29、mal.Impression: Small calcified at the top of the right lung. No acute lung disease. 33.胸部小结节。PA view of the chest was obtained. Both lung fields are well expanded.There is a small lung nodule 3mm size at the right mid lung. Bilateral apices are normal. Bilateral pleural spaces are normal. The cardi

30、ac contour is normal. The mediastinum and bilateral hila are normal.Impression: 3 mm nodule at right mid lung. Suggest comparison with old CXR to ensure stability, otherwise suggest CT chest.34.两肺纹理增多，未见明显感染之征象。AP view of the chest was obtained. Both lung fields are well expanded.There is no evidenc

31、e of lung mass or infiltrate. Mild increase of lung markings are present. Bilateral apices are normal. Bilateral pleural spaces are normal. The cardiac contour is normal. The mediastinum and bilateral hila are normal.Impression: Mild increase of lung markings. No focal infiltrate is seen.35.胸片侧位，肋骨骨

32、折Bilateral lungs are normal. The heart has normal size and contour. The mediastinum is normal. There is a fracture of right 7thaxillary rib.Impression: 1. Lungs are normal.2. Fracture of the right 7th axillary rib.36.胸部正侧位（右隔抬高，原因待查）PA and lateral views of the chest were obtained. Both lung fields are well expanded