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Transcript of Evolution of Radiology Reporting FINAL · PDF file unremarkable. The pancreas as visualized is...

  • EVOLUTION OF RADIOLOGY

    REPORTING

    Traditional Handwritten Report CONS: • Difficult to read • No images • No patient history • Slow turnaround time

    TRANSCRIBED VIA VOICE RECOGNITION

    Midland Imaging

    Transcribed Report

    PROS: • Easy to read • Standardized format • Consistent templatee

    CONS: •More steps in the process • Text only • No way to compare to priors • No patient history

    P R O S : • Faster turn around • Saves work�ow steps • Easy to read • Structured report

    C O N S : • Text only, no images • No way to compare to priors • No patient history

    Midland Imaging

    Name: Patient ID: History: Date of Birth: Study CT chest with contrast Facility: Physician: XXXXX XXXXXX, MD Date of Service: XX/XX/XXXX XX:XX:XX

    PROCEDURE: CT chest with contrast

    REASON FOR EXAM: Female, 59 years old. Congestion and a left upper lobe in�ltrate.

    RADIATION DOSAGE: (if Supplied by Facility): CTDlvol=(30.34) mGy, DLP=(523.87) mGycm.

    TECHNIQUE: High resolution transaxial imaging was preformed following intravenous administration of 100ml of Isovue 300 contrast material. Multi planar coronal and sagittal images were reformatted.

    COMPARISON: Prior CT scan 02/20/13 and radiographs 02/26/13

    P R O S : • Key data for holistic patient view • Patient history • Hyperlinks to images and reports from other modalities

    M U L T I M E D I A

    REPORT

    PROCEDURE: CT Abdomen with contrast

    CLINICAL INDICATION: Liver metastases (unknown primary tumor).

    TECHNIQUE: CT scan of the abdomen with and without contrast was performed ont he volumetric 64 slice CT scanner. The patient was scanned following the uncomplicated intravenous administration of 100 cc of Omnipaque 300. 3-D coronal reformatted images were obtained from the axial source images.

    COMPARISON: None

    FINDINGS: The lung bases are clear. The heart size is normal, without pericardial thickening or effusion. There are several hypodense lesions on both lobes of the liver the largest with a diameter of 54.00 mm that represent liver metastasis from unknown origin most probably. The spleen is normal in size and homogeneous in density. The stomach is partially collapsed, but is grossly unremarkable. The pancreas as visualized is normal. The gallbladder and biliary tree are unremarkable and there is no evidence for biliary dilatation. The adrenal glands are symmetric and normal. The kidneys are symmetrically unremarkable as well. The collecting system on the right is enlarged. The aorta is of normal caliber. Aortic calci�cations are present. There is no retroperitoneal lymphadenopathy. The porta hepatis region is clear. The bowel and mesentery, as visualized, are equally unremarkable. S/P total left hip replacement. The surrounding osseous structures are remarkable for mild degenerative spondylosis of the spine. Mild scoliosis of the lumbar spine No osteolytic or osteoblastic lesion is detected.

    IMPRESSION: 1. Several liver metastasis on both lobes from unknown origin. 2. S/P total left hip replacement

    Name: KING KEVIN ID: 201222091934 Accession No.: 9275000235689 Report Date: 23/12/2005

    Referring Physician: David Evans, MD 713-213-5479 davide@practice.com

    Report Information

    Midland Imaging

    • Results from prior exams for comparisons of progress • Quantitative analysis as graphs and charts for easy data interpretation • Short-cut links to other patient data and records

    • Hi-res images embedded in report • All-inclusive data and findings • Interactive • Automatic display of priors for visual of progress

    KING KEVIN71Y3MM201222091934Series Desc KEY_IMAGES FRGenerated from 5861-73

    Midland Imaging[23/12/2005.0:57:37] CurrentSW300mm

    carestream.com/vue-reporting

    PROCEDURE: CT Chest.

    CLINICAL INDICATION: Known left-sided squamous cell carcinoma of the lung post surgery with suspected lung metastsis

    TECHNIQUE: CT scan of the chest without contrast was performed on the GE volumetric 64 slice CT scanner. 3-D coronal reformatted images were obtained from the axial source images.

    COMPARISON: CT March 31 2012, CT June 23 2012

    Name: DAVIS DOROTHY ID: 201201061940 Accession No.: 9275000234567 Report Date: 28/09/2012

    Referring Physician: David Evans, MD 713-213-5479 davide@practice.com

    Report Information

    450

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    F05 F04 F07

    Vo lu

    m e

    31/03/2012 Baseline

    28/09/2012 Followup

    07/08/2012

    Date

    23/06/2012 Followup

    Target Lesions Name Target Description SeriesImageLong Diameter (mm)Short Diameter (mm)Volume (mm3)SUV Max (BW)

    B06 (F04) Target Lesion (Lung) 3 99 13 5.4 407.8 --

    B08 (F07) Target Lesion (Lung) 3 63 12.8 8.3 437.9 --

    B07 (F05) Target Lesion (Lung) 3 71 7.9 5.7 228.1 --

    Sum of target lesions (3): 33.7mm (Long) The automatic segmented lesions may not have been approved or adjusted

    Change Over Time Name Target Baseline

    2012-03-31 2012-06-23 2012-09-28 (Current)

    F05 Target Volume (mm3)

    Long (mm)

    Short (mm)

    109.4 (--)

    7.1 (--)

    3.5 (--)

    165.4 (+51.2%)

    7.3 (+4%)

    5.1 (+43.9%)

    140

    228.1 (+108.5%)

    7.9 (+12.2%)

    5.7 (+62.6%)

    170

    Midland Imaging

    2005-12-23, CT Abdomen

    Study Information

    Name Target Description Series Image Long Diameter (mm) Short Diameter (mm) Volume (mm3) SUV Max (BW)

    Other Lesions

    Signed By John Jennings, MD

    B01 Lesion (Liver) 5861 72 34.8 25.4 8888.7 --

    B02 Lesion (Liver) 5861 67 54 44.7 49936.2 --

    The automatic segmented lesions may not have been approved or adjusted.

    Midl and

    Imag ing

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    Curr ent

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    m

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