影像诊断报告的英文范文

Diagnostic Imaging Report

Patient Name: John Smith

Date: June 21, 2021

Imaging Modality: Magnetic Resonance Imaging (MRI)

Clinical Indication: Low back pain

Findings:

The MRI images of the lumbar spine reveal degenerative changes at multiple levels. There is disc desiccation and loss of disc height at L2-L3, L3-L4, L4-L5, and L5-S1 levels. There is also broad-based disc bulging at these levels contributing to mild spinal stenosis. Mild bilateral facet joint arthropathy is also noted at L2-L3, L3-L4, and L4-L5 levels.

At L4-L5 level, there is a small 3 mm disc protrusion causing mild impression upon the thecal sac. The disc is also abutting the left L4 nerve root.

The conus medullaris and cauda equina are normal in appearance. No significant osseous abnormality is noted.

Impression:

1. Multilevel degenerative changes in the lumbar spine with associated disc bulging and mild spinal stenosis.

2. Small 3 mm disc protrusion at L4-L5 level causing mild impression upon the thecal sac and abutting the left L4 nerve root.

Clinical Correlation:

The MRI findings correlate with the clinical indication of low back pain suggesting that multilevel degenerative changes and a small disc protrusion may be contributing to the patient's symptoms. Additional clinical and imaging evaluation may be warranted to further investigate the need for intervention.

Signed by:

Radiologist Name: Jane Doe, MD

Radiology Department: XYZ Hospital

Diagnostic Imaging Report

Patient Name: John Doe

Patient ID: 123456789

Date of Exam: 10/1/2021

Referring Physician: Dr. Jane Smith

Clinical History:

The patient is a 55-year-old male with a recent history of chest pain. He has a history of hypertension and hyperlipidemia.

Technique:

Chest radiograph was obtained in the posterior to anterior view. A computed tomography (CT) scan of the chest was performed with and without contrast.

Findings:

The chest radiograph shows mild cardiomegaly and bilateral pleural effusions. The CT scan reveals a large filling defect in the right pulmonary artery consistent with a pulmonary embolus. Additionally, there are multiple nodules in both lungs, with the largest measuring approximately 2 cm in diameter. These findings are highly suggestive of metastatic disease.

No other significant abnormality is seen. The osseous structures of the chest and upper abdomen appear normal.

Impression:

1. Pulmonary embolus in the right pulmonary artery.

2. Multiple lung nodules, highly suggestive of metastases.

3. Mild cardiomegaly and bilateral pleural effusions.

Recommendation:

The patient should be urgently referred to a hematologist for further workup and management of the pulmonary embolus. In addition, he should undergo further imaging to evaluate the nature and extent of the lung nodules, with consideration given to obtaining tissue for histopathological **ysis. Clinical correlation and follow-up are recommended.

Signed,

Dr. Smith, Radiologist