Sample Dictations
Dictation Guidelines for Residents (CT, MR and Ultrasound)
Reports should be signed at the end of each day if at all possible, by the next day at the latest.
I. DATE & TITLE OF EXAM:
2. CLINICAL HISTORY: Include symptoms and signs whenever possible.
3. COMPARISON EXAMS: Indicate kind of exam, and date of exam
e.g. CT of the chest, abdomen and pelvis of /dated -/-/----. (not just the date).
So don’t say “Comparison exam: 2/3/2009.”
**Bring the relevant comparison exam results to the attention of the attending at time of read out.
**Always look up other clinical/ surgical history on the patient (on “Sunrise Clinical Manager”) prior to a read out with the attending.
4. COMMENT:
a) Indicate enteric, rectal, intravenous contrast (or not) and area of coverage.
b) If intravenous contrast was not administered, state the reason:
E.g.;
-as per the renal stone/ lung nodule protocol.
-due to a high creatinine level
-as per the requisition/requesting physician.
c) If intravenous contrast was administered, state any significant patient reaction, or state that there was no event
E.g. –cc of Ultravist was injected intravenously without event or
…uneventful intravenous administration of –cc of Ultravist…
5. FINDINGS: A physician should be able to draw an accurate mental image of severity/significance of findings from your description.
a) Use subheadings if multiple body parts (e.g. ABDOMEN (CT FINDINGS): then PELVIS (CT FINDINGS), etc.)
b) Organize and discuss related findings.
e.g. Do not discuss the liver, then the spleen, then the liver again.
c) Do not dictate findings as a solid paragraph, use more paragraphs. It is easier for clinicians and the proofreading attending radiologists to follow.
d) Quantitatively/Quantitatively define abnormalities as the following:
either
e) Do not use slang terms in reports (e.g. CA, mets., hydro., etc.)
f) If a finding is obvious (e.g. gallstone, cyst) do not describe it (e.g. “echogenic shadowing focus consistent with gallstone” or “anechoic structure consistent with cyst”), just say what it is.
g) If there is a relevant abnormality and there is a prior exam you must state what, if any, interval change has occurred
i.e. increased/decreased or unchanged.
6.IMPRESSION:
a) Answer the questions posed by the clinician early in the impression!
b) List important results first, leave trivia (e.g. bone islands etc.) out of impression.
c) Differential diagnosis and recommendations for further imaging should ONLY be in the
impression, (because this shortens reports and that is where it counts!).
d) Differential diagnosis should be given in order: from most likely to least likely
e) Avoid repeating long descriptions from findings section in the impression
(Be brief).
g) When findings are called to a clinical provider, document
-the name of the individual spoken to
-date and time of call
h) As a rough guideline, your impression may be too long if it contains more than 6(six) items
i) After editing the report read the findings and be certain any important findings have been put into the impression.
j) Most importantly read through a finished report and ensure the above have been done, and there are no typographical errors and no blanks before sending it to the attending radiologist.
Know the ACR Standard for Communication
http://www.acr.org/SecondaryMainMenuCategories%2fquality_safety%2fguidelines%2fdx%2fcomm_diag_rad.aspx
A. Buadu, M.D.
6/2009
I. DATE & TITLE OF EXAM:
2. CLINICAL HISTORY: Include symptoms and signs whenever possible.
3. COMPARISON EXAMS: Indicate kind of exam, and date of exam
e.g. CT of the chest, abdomen and pelvis of /dated -/-/----. (not just the date).
So don’t say “Comparison exam: 2/3/2009.”
**Bring the relevant comparison exam results to the attention of the attending at time of read out.
**Always look up other clinical/ surgical history on the patient (on “Sunrise Clinical Manager”) prior to a read out with the attending.
4. COMMENT:
a) Indicate enteric, rectal, intravenous contrast (or not) and area of coverage.
b) If intravenous contrast was not administered, state the reason:
E.g.;
-as per the renal stone/ lung nodule protocol.
-due to a high creatinine level
-as per the requisition/requesting physician.
c) If intravenous contrast was administered, state any significant patient reaction, or state that there was no event
E.g. –cc of Ultravist was injected intravenously without event or
…uneventful intravenous administration of –cc of Ultravist…
5. FINDINGS: A physician should be able to draw an accurate mental image of severity/significance of findings from your description.
a) Use subheadings if multiple body parts (e.g. ABDOMEN (CT FINDINGS): then PELVIS (CT FINDINGS), etc.)
b) Organize and discuss related findings.
e.g. Do not discuss the liver, then the spleen, then the liver again.
c) Do not dictate findings as a solid paragraph, use more paragraphs. It is easier for clinicians and the proofreading attending radiologists to follow.
d) Quantitatively/Quantitatively define abnormalities as the following:
either
- with a measurement as appropriate or
- as large , moderate, small, minimal (e.g. for effusions, atelectasis, ascites), or
- as severe, moderate, mild (e.g. hydronephrosis, bile duct dilatation). If you just say “right side atelectasis” one can’t tell if it is trivial or if the entire lung collapsed.
e) Do not use slang terms in reports (e.g. CA, mets., hydro., etc.)
f) If a finding is obvious (e.g. gallstone, cyst) do not describe it (e.g. “echogenic shadowing focus consistent with gallstone” or “anechoic structure consistent with cyst”), just say what it is.
g) If there is a relevant abnormality and there is a prior exam you must state what, if any, interval change has occurred
i.e. increased/decreased or unchanged.
6.IMPRESSION:
a) Answer the questions posed by the clinician early in the impression!
b) List important results first, leave trivia (e.g. bone islands etc.) out of impression.
c) Differential diagnosis and recommendations for further imaging should ONLY be in the
impression, (because this shortens reports and that is where it counts!).
d) Differential diagnosis should be given in order: from most likely to least likely
e) Avoid repeating long descriptions from findings section in the impression
(Be brief).
- Avoid (if possible) radiology jargon in impression (e.g. “low attenuation focus in liver”).
g) When findings are called to a clinical provider, document
-the name of the individual spoken to
-date and time of call
h) As a rough guideline, your impression may be too long if it contains more than 6(six) items
i) After editing the report read the findings and be certain any important findings have been put into the impression.
j) Most importantly read through a finished report and ensure the above have been done, and there are no typographical errors and no blanks before sending it to the attending radiologist.
Know the ACR Standard for Communication
http://www.acr.org/SecondaryMainMenuCategories%2fquality_safety%2fguidelines%2fdx%2fcomm_diag_rad.aspx
A. Buadu, M.D.
6/2009
Generic Extremity Bone:
Impression: No evidence of acute fracture or dislocation.
Discussion: [] views of the [] were obtained. There are no prior studies for comparison
Bone mineralization is appropriate for the patient's age. There is no evidence of acute fracture or dislocation. [If there is a history of trauma, and the patient’s pain persists, repeat radiographs are recommended in 7-10 days to evaluate for occult fracture].
C-spine x-ray:
Impression: No evidence of acute fracture or dislocation of the cervical spine.
Discussion: [] views of the cervical spine were obtained. There are no prior studies for comparison.
Bone mineralization is appropriate for the patient’s age. Spinal alignment is within normal limits. There is no evidence of acute fracture or dislocation. The prevertebral soft tissues are unremarkable.
Chest X-ray One View:
Impression: Limited satisfactory portable.
Discussion: A single frontal view of the chest is reviewed with no prior studies for comparison.
The cardiomediastinal sillouette is unremarkable. The lungs are clear.
Chest X-ray Two Views:
Impression: No significiant abnormalities.
Discussion: Frontal and lateral views of the chest are reviewed with no prior studies for comparison.
The cardiomediastinal sillouette is unremarkable. The lungs are clear.
Abdominal Series:
Impression: No significant abnormalities.
Discussion: A frontal view of the chest and supine and upright views of the abdomen were obtained with no prior studies for comparison.
The cardiomediastinal sillouette is unremarkable. The lungs are clear. There is no free air under the diaphragms. The bowel gas pattern is unremarkable. [There is no evidence of abnormal calcification in the abdomen.] [There is no evidence of organomegally.] The visualized osseous structures are unremarkable. [There are degenerative changes of the visualized osseous structures].
Impression: No evidence of acute fracture or dislocation.
Discussion: [] views of the [] were obtained. There are no prior studies for comparison
Bone mineralization is appropriate for the patient's age. There is no evidence of acute fracture or dislocation. [If there is a history of trauma, and the patient’s pain persists, repeat radiographs are recommended in 7-10 days to evaluate for occult fracture].
C-spine x-ray:
Impression: No evidence of acute fracture or dislocation of the cervical spine.
Discussion: [] views of the cervical spine were obtained. There are no prior studies for comparison.
Bone mineralization is appropriate for the patient’s age. Spinal alignment is within normal limits. There is no evidence of acute fracture or dislocation. The prevertebral soft tissues are unremarkable.
Chest X-ray One View:
Impression: Limited satisfactory portable.
Discussion: A single frontal view of the chest is reviewed with no prior studies for comparison.
The cardiomediastinal sillouette is unremarkable. The lungs are clear.
Chest X-ray Two Views:
Impression: No significiant abnormalities.
Discussion: Frontal and lateral views of the chest are reviewed with no prior studies for comparison.
The cardiomediastinal sillouette is unremarkable. The lungs are clear.
Abdominal Series:
Impression: No significant abnormalities.
Discussion: A frontal view of the chest and supine and upright views of the abdomen were obtained with no prior studies for comparison.
The cardiomediastinal sillouette is unremarkable. The lungs are clear. There is no free air under the diaphragms. The bowel gas pattern is unremarkable. [There is no evidence of abnormal calcification in the abdomen.] [There is no evidence of organomegally.] The visualized osseous structures are unremarkable. [There are degenerative changes of the visualized osseous structures].
Impression: No evidence of pulmonary embolism.
Procedure: Axial CT images of the chest were obtained following the administration of [] ml [] intravenous contrast. There are no prior studies for comparison.
Findings: There is no evidence of pulmonary embolism. [There are no central or large peripheral pulmonary emboli.]
There is no evidence of axillary, hilar or mediastinal lymphadenopathy.
The cardiomediastinal structures appear unremarkable.
The lungs are clear [except for minor scarring and basilar dependent atelectasis.]
The visualized upper abdominal organs are unremarkable.
There are no suspicious superficial soft tissue or osseous abnormalities.
CT Chest:
Impression: No significant abnormalities.
Procedure: Axial CT images of the chest were obtained following the administration of [] intravenous contrast. There are no prior studies for comparison.
Findings: The cardiomediastinal structures are within normal limits. There is no evidence of hilar, mediastinal or axillary lymphadenopathy.
The lungs are clear [except for minor dependent atelectasis and scarring].
The visualized upper abdominal organs are unremarkable.
No suspicious superficial soft tissue or osseous abnormalities are present.
CT Abd/Pelv:
Impression: No significant abnormalities.
Procedure: Axial CT images of the abdomen and pelvis were obtained following the administration of [] intravenous contrast. There are no prior studies for comparison.
Findings: The lung bases are clear [except for minor scarring and dependent atelectasis].
There is no free air [or free fluid] in the abdomen or pelvis.
The liver, spleen, adrenal glands, kidneys, gallbladder and pancreas appear unremarkable. The large and small bowel are within normal limits. The appendix appears unremarkable. The pelvic structures appear unremarkable.
There are no suspicious superficial soft tissue or osseous abnormalities.
Renal Stone Protocol CT:
Impression: No evidence of nephrolithiasis or other significant abnormality.
Procedure: Axial CT images of the abdomen and pelvis were obtained without the administration of [] intravenous contrast for renal stone protocol. There are no prior studies for comparison. Coronal reconstructions were provided.
Findings: The lung bases are clear [except for minor scarring and dependent atelectasis].
There is no free air in the abdomen or pelvis.
The liver, spleen, adrenal glands, kidneys, gallbladder and pancreas appear unremarkable. There is no evidence of obstructing nephrolithiasis or ureteral stone. The large and small bowel are within normal limits. The appendix appears unremarkable. The pelvic structures appear unremarkable.
There are no suspicious superficial soft tissue or osseous abnormalities.
Impression: No significant abnormalities.
Procedure: Axial CT images of the neck were obtained following the administration of [] ml Oxilan intravenous contrast. There are no prior studies for comparison. Coronal and sagittal reconstructions are provided.
Findings: There is no evidence of acute fracture or dislocation of the cervical spine. The prevertebral soft tissues appear unremarkable. Alignment is within normal limits. The opacified vascular structures are within normal limits with no evidence of significant stenosis, aneurism formation or dissection. The visualized soft tissues of the neck are within normal limits.
CT Cervical Spine:
Impression: No evidence of acute fracture or dislocation of the cervical spine.
Discussion: Axial CT images of the cervical spine were obtained without intravenous contrast. There are no prior studies for comparison. Coronal and sagittal reconstructions were provided.
Findings: Bone mineralization is appropriate for the patient’s age. Spinal alignment is within normal limits. There is no evidence of acute fracture or dislocation. The prevertebral soft tissues are unremarkable.
CT Head:
Impression: No significant abnormalities:
Procedure: Axial CT images of the head were obtained without the administration of intravenous contrast. There are no prior studies for comparison.
Findings: The bony calvarium, paranasal sinuses, and orbital structures are within normal limits. The CSF-containing spaces appear unremarkable. There are no significant intra or extra-axial abnormalities.
CT Head and facial bones:
Impression: 1) No acute intracranial abnormalities. 2) No facial bone fractures.
Procedure: Axial CT images of the head and facial bones were obtained without the administration of intravenous contrast. There are no prior studies for comparison.
Findings: The facial bones, bony calvarium, paranasal sinuses, and orbital structures are within normal limits. The CSF-containing spaces appear unremarkable. There are no significant intra-axial or extra-axial abnormalities.
CT Old Head:
Impression: Age related brain substance loss and microangiopathic ischemic changes with no acute intracranial abnormalities.
Procedure: Axial images of the head were obtained without the administration of intravenous contrast. There are no prior studies for comparison.
Findings: The calvarium, paranasal sinuses, and orbital structures are within normal limits. There is age-related generalized brain substance loss, and there are deep white matter ischemic changes. There are no other significant intra-axial or extra-axial abnormalities.
Lumbar spine CT:
Impression:
1) No evidence of acute fracture of the lumbar spine.
2) Degenerative changes of the lumbar spine as described below.
Procedure: Axial images of the lumbar spine were obtained without the administration of [] intravenous contrast. There are no prior studies for comparison. Coronal and sagittal reconstructions were provided.
Findings: There is no evidence of acute fracture or dislocation of the lumbar spine. The prevertebral soft tissues appear unremarkable. Alignment is within normal limits.
At T12-L1, disk space height is well preserved and there is no significant posterior disk bulge or herniation. There is no significant canal or foraminal stenosis.
At L1-L2…
At L2-L3…
At L3-L4…
At L4-L5…
At L5-S1…
Pelvic US:
Impression: No significant abnormalities.
Discussion: Pelvic ultrasound was performed using transabdominal and transvaginal approaches. There are no prior studies for comparison.
Findings: The uterus measures [] cm. The endometrium is - mm thick. The bladder is [partially] distended with urine and appears unremarkable.
The right ovary measures []. The left ovary measures []. Both ovaries are of normal sonographic appearance. Doppler flow is noted to both ovaries, making torsion unlikely.
There is no free fluid in the pelvis.
Abdomen US:
Impression: No significant abnormalities.
Procedure: Ultrasound examination of the abdomen was performed. There are no prior studies for comparison.
Findings: The liver is of normal size and echotexture. There are no focal mass lesions on the presented images. Normal hepatopetal flow is demonstrated in the portal vein. The gallbladder is well distended with no evidence of cholelithiasis, wall thickening, or pericholecystic fluid. The common bile duct measures [] mm diameter. There is no evidence of intra or extrahepatic biliary ductal dilatation.
The right kidney measures []. The left kidney measures []. The kidneys appear unremarkable with no evidence of hydronephrosis.
The spleen measures [] in span. The visualized portion of the pancreas and abdominal aorta appear unremarkable. The visualized inferior vena cava appears unremarkable.
Negative DVT Study:
Impression: No evidence of DVT in the bilateral lower extremities.
Procedure: Doppler ultrasound of the bilateral lower extremities was performed. There are no prior studies for comparison.
Findings: There is normal doppler venous flow and compressibility of the common femoral, superficial femoral and popliteal veins. There is no evidence of intraluminal echogenic material to suggest deep vein thrombosis.
1st trimester OB US:
Impression: Single live intrauterine gestation of [] weeks [] days gestational age.
Procedure: Obstetric ultrasound was performed via transabdominal and transvaginal approaches. There are no prior studies for comparison.
Findings: The uterus contains a gestational sac and measures []. The mean gestational sac diameter is []. An embryo is seen with a crown to length of [] consistent with a gestational age of []. The placenta appears unremarkable. A fetal heart rate of [] is detected.
There is no free fluid in the pelvis.
The bladder is partially distended with urine, [is decompressed around a Foley catheter] and is otherwise unremarkable.
The right ovary measures []. The left ovary measures []. The ovaries appear unremarkable. Color Doppler flow is documented to the ovaries.
Impression: No significant abnormalities.
Discussion: Pelvic ultrasound was performed using transabdominal and transvaginal approaches. There are no prior studies for comparison.
Findings: The uterus measures [] cm. The endometrium is - mm thick. The bladder is [partially] distended with urine and appears unremarkable.
The right ovary measures []. The left ovary measures []. Both ovaries are of normal sonographic appearance. Doppler flow is noted to both ovaries, making torsion unlikely.
There is no free fluid in the pelvis.
Abdomen US:
Impression: No significant abnormalities.
Procedure: Ultrasound examination of the abdomen was performed. There are no prior studies for comparison.
Findings: The liver is of normal size and echotexture. There are no focal mass lesions on the presented images. Normal hepatopetal flow is demonstrated in the portal vein. The gallbladder is well distended with no evidence of cholelithiasis, wall thickening, or pericholecystic fluid. The common bile duct measures [] mm diameter. There is no evidence of intra or extrahepatic biliary ductal dilatation.
The right kidney measures []. The left kidney measures []. The kidneys appear unremarkable with no evidence of hydronephrosis.
The spleen measures [] in span. The visualized portion of the pancreas and abdominal aorta appear unremarkable. The visualized inferior vena cava appears unremarkable.
Negative DVT Study:
Impression: No evidence of DVT in the bilateral lower extremities.
Procedure: Doppler ultrasound of the bilateral lower extremities was performed. There are no prior studies for comparison.
Findings: There is normal doppler venous flow and compressibility of the common femoral, superficial femoral and popliteal veins. There is no evidence of intraluminal echogenic material to suggest deep vein thrombosis.
1st trimester OB US:
Impression: Single live intrauterine gestation of [] weeks [] days gestational age.
Procedure: Obstetric ultrasound was performed via transabdominal and transvaginal approaches. There are no prior studies for comparison.
Findings: The uterus contains a gestational sac and measures []. The mean gestational sac diameter is []. An embryo is seen with a crown to length of [] consistent with a gestational age of []. The placenta appears unremarkable. A fetal heart rate of [] is detected.
There is no free fluid in the pelvis.
The bladder is partially distended with urine, [is decompressed around a Foley catheter] and is otherwise unremarkable.
The right ovary measures []. The left ovary measures []. The ovaries appear unremarkable. Color Doppler flow is documented to the ovaries.
Obstetric Ultrasound Dictation:
There is a (single) (twin etc) intrauterine gestation with a biparietal diameter, head circumference, abdominal circumference and femoral length corresponding to gestational ages -,-,-, - respectively.
The overall estimated gestational age is ---based on this examination alone.
(Estimated fetal weight): (Comment if Cephalic Index is abnormal)
Estimated date of delivery based on this examination :
Fetal presentation: (cephalic, breech…)
Placental location: (anterior, posterior, in the fundus.)
Placenta previa: present/absent.
The maternal cervix measures ----and is normal.
Amniotic Fluid Index is ---- and is (normal, increased, decreased)
Fetal heart rate is ---and is normal.
Fetal Head: Ventricles are normal in size. The posterior fossa and midline structures are (normal).
In the fetal face, the upper lip is (normal).
Fetal Chest: A normal 4 chamber heart is seen/not seen/ normal/not normal.
Fetal Abdomen:
Left sided stomach: seen
Fetal kidneys: (appear normal.)
Cord Insertion: Normal/abnormal
Fetal Pelvis:
3 vessel cord: present/ not seen
Fetal bladder: Seen
-Fetal Spine: normal/abnormal
-Extremities: any visualized
Liver Transplant Dictation:
History: []
Comparison examination: []
Comment: Real time gray scale and duplex Doppler ultrasound examination of a transplant liver was performed.
Findings:
Liver Parenchyma:
Echogenicity: [Normal][Increased].
Focal lesions: [].
Fluid collections: [].
Bile ducts: []
Hepatic Vasculature: []
Portal vein waveforms and direction of flow: []
Portal vein velocities:
Main: []
Right: []
Left: []
Hepatic vein waveforms: [Normal] [Dampened]
Hepatic vein velocities:
Right: []
Middle: []
Left: []
Hepatic artery velocities and resistive indices:
Main: []
Right: []
Left: []
Inferior Vena Cava: [Patent]
Splenic Vein velocity: []
Intraabdominal free fluid: []
Other: []
Impression:
Renal Transplant Dictation:
History: []
Comparison examination: []
Comment: Real time gray scale and duplex Doppler ultrasound examination of a [right][left] lower quadrant transplant kidney was performed.
Findings:
Transplant Kidney:
Echogenicity: [ ]
Focal lesions: [ ]
Hydronephrosis: [Present][Absent]
Peritransplant fluid: []
Intrarenal arteries:
Waveforms: [Normal]
Resistive indices: []
Main renal and iliac vessels: [patent]
Waveforms: []
Bladder: [Distended][Contracted].
Other: []
Impression:
Double Contrast Barium Enema:
Clinical statement: []
Technique: Standard air contrast barium enema was performed.
Comparison: []
Findings:
Scout film of the abdomen demonstrates an unremarkable bowel gas pattern. No pathologic intra-abdominal calcifications are noted.
The colon is visualized in its entirety. The colonic mucosa appears normal. No annular constricting or obstructing lesions are identified. No polyps are noted. Reflux is seen into a normal appearing terminal ileum.
Impression: Normal double contrast barium enema.
Double Contrast Esophogram:
Clinical statement: [ ]
Technique: A standard air contrast esophagram was performed.
Comparison: []
Findings:
The patient swallowed barium without difficulty. The oral and pharyngeal phases of swallowing are normal. There is no nasal regurgitation, laryngeal penetration or aspiration identified. Esophageal motility is within the limits of normal.
The esophagus is structurally normal without intrinsic or extrinsic masses. The esophageal mucosa appears normal. No gastroesophageal reflux was demonstrated during this examination, despite the performance of maneuvers to elicit GE reflux.
Impression: Unremarkable esophagram.
Small Bowel Series:
Clinical statement: []
Technique: Standard barium small bowel series was performed with multiple overhead radiographs. In addition, the small bowel was examined fluoroscopically intermittently throughout the examination.
Comparison: []
Findings:
The small bowel is of normal course and caliber. No intrinsic or extrinsic mass lesions are identified. The transit time is within normal limits. The terminal ileum appears normal.
Impression: Unremarkable small bowel series.
Double Contrast Upper GI:
Clinical statement: []
Technique: A standard air contrast upper GI series was performed.
Comparison: []
Findings:
The patient swallowed barium without difficulty. The esophagus is structurally normal without intrinsic or extrinsic masses. The esophageal mucosa appears normal.
The stomach demonstrates normal distensibility. No mass or ulceration is identified. There is no evidence of gastritis. The duodenal bulb and sweep are unremarkable. No ulcers can be identified.
No gastroesophageal reflux was demonstrated during this examination, despite the performance of maneuvers to elicit GE reflux.
Impression: Unremarkable upper GI series.
Hysterosalpingogram:
Clinical Statement: []
Technique: A hysterosalpingogram was performed by the referring physician, [ ], of the [obstetric/gynecology] [reproductive endocrinology] service and [ ] images are submitted for review.
Comparison: []
Findings:
The endometrial cavity is normal in contour without any filling defects.
Contrast is seen in the fallopian tubes bilaterally which are normal in course and caliber. There is free intraperitoneal spill of contrast bilaterally.
Impression: Normal hysterosalpingogram.
IVP :
Clinical Statement: []
Technique: An intravenous pyelogram was performed following the intravenous administration of [] contrast.
Comparison: []
The scout film demonstrates a normal bowel gas pattern. There is no evidence of masses or organomegaly. There are no radiopaque calculi visible in the kidneys or along the ureteral tracts.
Following the uneventful administration of 100 cc's of Omnipaque 300 intravenously, the nephrograms and pyelograms are prompt and bilateral. Kidneys are normal in size, shape, and axis. There are no masses evident.
There is no dilatation or filling defects of the renal calyces or pelves bilaterally. The ureters are normal in course and calibre, without any filling defects.
The bladder is normal in size, shape, and contour. No filling defects are evident. There is minimal post-void residual.
Impression: Normal IVP
Clinical statement: []
Technique: Standard air contrast barium enema was performed.
Comparison: []
Findings:
Scout film of the abdomen demonstrates an unremarkable bowel gas pattern. No pathologic intra-abdominal calcifications are noted.
The colon is visualized in its entirety. The colonic mucosa appears normal. No annular constricting or obstructing lesions are identified. No polyps are noted. Reflux is seen into a normal appearing terminal ileum.
Impression: Normal double contrast barium enema.
Double Contrast Esophogram:
Clinical statement: [ ]
Technique: A standard air contrast esophagram was performed.
Comparison: []
Findings:
The patient swallowed barium without difficulty. The oral and pharyngeal phases of swallowing are normal. There is no nasal regurgitation, laryngeal penetration or aspiration identified. Esophageal motility is within the limits of normal.
The esophagus is structurally normal without intrinsic or extrinsic masses. The esophageal mucosa appears normal. No gastroesophageal reflux was demonstrated during this examination, despite the performance of maneuvers to elicit GE reflux.
Impression: Unremarkable esophagram.
Small Bowel Series:
Clinical statement: []
Technique: Standard barium small bowel series was performed with multiple overhead radiographs. In addition, the small bowel was examined fluoroscopically intermittently throughout the examination.
Comparison: []
Findings:
The small bowel is of normal course and caliber. No intrinsic or extrinsic mass lesions are identified. The transit time is within normal limits. The terminal ileum appears normal.
Impression: Unremarkable small bowel series.
Double Contrast Upper GI:
Clinical statement: []
Technique: A standard air contrast upper GI series was performed.
Comparison: []
Findings:
The patient swallowed barium without difficulty. The esophagus is structurally normal without intrinsic or extrinsic masses. The esophageal mucosa appears normal.
The stomach demonstrates normal distensibility. No mass or ulceration is identified. There is no evidence of gastritis. The duodenal bulb and sweep are unremarkable. No ulcers can be identified.
No gastroesophageal reflux was demonstrated during this examination, despite the performance of maneuvers to elicit GE reflux.
Impression: Unremarkable upper GI series.
Hysterosalpingogram:
Clinical Statement: []
Technique: A hysterosalpingogram was performed by the referring physician, [ ], of the [obstetric/gynecology] [reproductive endocrinology] service and [ ] images are submitted for review.
Comparison: []
Findings:
The endometrial cavity is normal in contour without any filling defects.
Contrast is seen in the fallopian tubes bilaterally which are normal in course and caliber. There is free intraperitoneal spill of contrast bilaterally.
Impression: Normal hysterosalpingogram.
IVP :
Clinical Statement: []
Technique: An intravenous pyelogram was performed following the intravenous administration of [] contrast.
Comparison: []
The scout film demonstrates a normal bowel gas pattern. There is no evidence of masses or organomegaly. There are no radiopaque calculi visible in the kidneys or along the ureteral tracts.
Following the uneventful administration of 100 cc's of Omnipaque 300 intravenously, the nephrograms and pyelograms are prompt and bilateral. Kidneys are normal in size, shape, and axis. There are no masses evident.
There is no dilatation or filling defects of the renal calyces or pelves bilaterally. The ureters are normal in course and calibre, without any filling defects.
The bladder is normal in size, shape, and contour. No filling defects are evident. There is minimal post-void residual.
Impression: Normal IVP
