Home - The American College of Foot & Ankle Orthopedics ...
Radiologic Report Standardized FormatThe radiologic interpretation should be separate formal report, not a paragraph with the SOAP note. The following areas should be addressed in your report.Report InformationExamplesPatient detailsName, age, sex, etc.Reason for study (relevant clinical information)Painful 1st MPJ, injured 5th toe, post-?‐op evaluation, etc. Rule out arthritis/fracture/infection, etc.General OverviewList images and body partDP/AP, medial or lateral oblique, lateral, axial, …of the right/left toes/foot/ankleImage quality: density/brightnessIncreased or decreased radiographic density; low contrast; overexposure (saturation)Image quality: artifactsStatic electricity; scratches on image; double exposureImage quality: technical errors; study limitationsFoot not positioned correctly in oblique view; image blurry due to patient movementFoot position (overall)Foot appears pronated/supinated, everted/inverted, etc., weight/non-?‐weight bearingSoft TissuesDensity/volumeIncreased soft tissue density and volume (where); metallic-?‐ like density resembling needle (where)BonesPosition (of one bone relative to another)Hallux abductus angle incrased; calcaneal inclination angle decreasedForm (bone shape)Diaphysis is narrow/thing; 4th metatarsal is shortArchitecture (outer margin& inner structure)Primary trabeculations are prominent; periosteal reaction along lateral diaphysis; discontinuity of cortexDensity (in bone)Geographic increased density in 2nd metatarsal head multiple spotty decreased densities in all lesser metatarsal headsJointsJoint space1st MPJ space is unevenly decreasedApposition50% apposition between 1st matatarsal base and medial cuneiformJoint marginsOsteophyte/erosion along medial aspect of 2nd metatarsal headSubchondral bone platePre-?‐erosion (skip pattern) medial aspect of 3rd metatarsal headImpressionAnswer clinical questionNo evidence of fractureDiagnosis/diff. diagnosisOsteoarthritis vs. gouty arthritisRecommendationsCT to assess possible tarsal coalitionIf previous studies exist and are available for review, they should be compared and findings of any changed noted.Sign and date the report.John Doe, DPMDate ................
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