바른본 병원 판독 form

echocardiogram

판독폼 (내과에서 한것)

** poor echo window
Normal LV systolic function without RWMA (EF: 67% )
Normal diastolic function E/a 1.22
Normal chamber size and thickeness
No MR no AR
No pericardial effusion or mall, thickenss
Normal size IVC with good collapse

Cardiac echo

[Reading]

The EF is %

No abnormal flow or motion in MV, TV and AV.

No relaxation abnormality

No LA enlargement

[Conclusion]

The EF is %

No abnormal flow or motion in MV, TV and AV.

REC) clinical correlation

Carpal tunnel syndrome

[Reading]

Hypoechoic swelling of median nerve at carpal tunnel level

flattening of median nerve at hook of hamate level with proximal swelling

[Conclusion]

carpal tunnel syndrome

REC) clinical correlation

Carotid US

[Reading]

Carotid doppler

IMT(Intima-media thickness )

Rt mm

Lt mm

->WNL

Spectral wave form, PSV and EDV

WNL in both CCA, ECA and ICA

reference

1) CCA

>50% CCA stenosis: PSV > 182 cm/sec

2)ECA

>50% ECA stenosis :PSV > 130 cm/sec

>75% ECA stenosis:PSV > 220 cm/sec

3) ICA

Normal : PSV<125cm/sec
50~69% stenosis: PSV 125~230cm/sec

>70% stenosis: PSV > 230cm/sec

[Conclusion]

no significant abnormality

REC) clinical correlation and F/U

x-ray-----

척추 측만

[Reading]

No definite active lesion in the lung and pleura.

Normal size and shape of heart.

No pleural effusion

Thoracic scoliosis

[Conclusion]

No definite active lung lesion

Thoracic scoliosis

REC) clinical correlation and F/U

TKRA

[Reading]

S/P TKRA, Rt Lt
No other remarkable change

[Conclusion]

S/P TKRA, Rt Lt

No post op unusual finding

REC) clinical correlation and F/U

Sprain

[Reading]

Straightening of L spine curvature

No significant disc space narrowing

[Conclusion]

r/o L spine sprain

REC) clinical correlation

SPN

[Reading]

suspicious small nodular opacity in

-> artifact vs. true pathology

No cardiomegaly
No pleural effusion

[Conclusion]

suspicious small nodular opacity in

-> artifact vs. true pathology

REC) clinical correlation and 2-3 month f.u chest PA and Lat

Skull

[Reading]

1. No evidence of skull fracture.

2. No other remarkable findings.

[Conclusion]

No detectable evidence of skull fracture

REC) clinical correlation and if clinically warranted, brain CT

Shoulder reverse arthroplasty

[Reading]

s/p reverse total shoulder arthroplasty

No post op unusual finding

No other change

[Conclusion]
s/p reverse total shoulder arthroplasty

REC) clinical correlation and F/U

Sesamoid

[Reading]

lateral displacement of hallux sesamoid bones, both

No definite bony fracture

[Conclusion]

lateral displacement of hallux sesamoid bones, both

REC) clinical correlation

Rib 이 있는

[Reading]

rib 이 있는 가장 lower VB 를 T12 로 count 하였음.

[Conclusion]

Rib series

[Reading]

No visible evidence of rib fracture on x-ray

[Conclusion]

No detectable rib fracture

REC) clinical correlation and F/U or if clinically needed, further w.u

Prominent hilum

[Reading]

prominent hilum, (G)

-> R/o vascular shadow

ddx. R/O space occupying lesion

[Conclusion]

REC) clinical correlation and 2-3 month f/u chest PA and Lat

Prominent aorta

[Reading]

No definite active lung disease.

Cardiomegaly.

Prominent aorta

Rt diaphragm eventration
[Conclusion]

Cardiomegaly.

Prominent aorta

REC) clinical correlation and regular F/U

Addendum: chest PA shows no definite active lung lesion, but cannot exclude of hidden lesion
at retrocardiac, both hilar, rib regions, bronchovascular bundle area and diaphragm area

Post op

[Reading]

S/P

No significant post op unusual finding

[Conclusion]

No significant post op unusual finding

REC) clinical correlation and F/U

Pincer

[Reading]

overcorverage of femoral head by acetabulum

degenerative change in both femoroacetabular joint

[Conclusion]

r/o pincer type femoroacetabular impingement, both

REC) clinical correlation and consider further w.u

Pelvis x-ray

[Reading]

Degenerative change in both femoroacetabular joint

No definite bony fracture

[Conclusion]

Degenerative change in both femoroacetabular joint

REC) cllinical correlation if clinically needed, consider pelvis MR with full cover of sacrum
Old tb

[Reading]

Multiple reticulonodular densities with small calcified nodules and fibrosis are noted in .

No Cardiomegaly

No Pleural thickening

[Conclusion]

R/o old Tbc in

REC) clinical correlation and F/U

OA

[Reading]

OA of both knees, KL grade

[Conclusion]

same as above.

No other

[Reading]

s/p

no other significant change

[Conclusion]
s/p

no fx

[Reading]

no definite evidence of acute bony fracture.

[Conclusion]

no definite evidence of fracture.

REC) clinical correlation

MS x-ray

[Reading]

There is no definite destructive lesions in visible bones.

Joint spaces are preserved.

Others are not remarkable.

all bony structure, soft tissue lung, abdomen, spine, check

[Conclusion]

No visible bony abnormality

REC) clinical correlation and F/U or if clinically warranted, consider CT or MR with full cover on
ax, cor, sag
MLD/ ULBD

[Reading]

unilateral laminectomy for bilateral decompression (ULBD)

Microdiscectomy(MLD)

no post op unusual finding

no other change

[Conclusion]

unilateral laminectomy for bilateral decompression (ULBD)

Microdiscectomy(MLD)

REC) clinical correlation and f/U

Knee hemiarthro

[Reading]

s/p hemiarthroplasty

no post op unusual finding

no other change

[Conclusion]

s/p hemiarthroplasty

no post op unusual finding

REC) clinical correlation and f/u

KL34

[Reading]

definite osteophytes on tibia patellar and femoral condyle. moderate severe joint space
narrowing

subchondral sclerosis

[Conclusion]

K-L grade 3 4 DJD, both

REC) clinical correlation, if clinically warranted, consider knee MR

KL1-2

[Reading]

Dountful joint space narrowing and possible osteophyte lipping

minute Osteophytes on tibia patella and femoral condyle. unimpaired joint spaces.

[Conclusion]
K-L grade 1 DJD, both

K-L grade 2 DJD, both

REC) clinical correlation and f/U

Intertrochanteric fx

[Reading]

s/p Intramedullary hip screw for intertrochanteric fracture

[Conclusion]

s/p Intramedullary hip screw for intertrochanteric fracture

REC) clinical correlation and f/u

Interbody

[Reading]

S/P interbody cage insertion at c4-5, c5-6

No other change

[Conclusion]

S/P interbody cage insertion at c4-5, c5-6

REC) clinical correlation and f/u

HTO

[Reading]

S/P HTO

No post op unusual finding

No other significant change

[Conclusion]

S/P HTO

REC) clinical correlation and F/U

Hand OA

[Reading]

OA change in DIP joints of both 2,3,4,5th fingers and IP joint of both 1st fingers

NO definite bony fracture

[Conclusion]

OA change in DIP joints of both 2,3,4,5th fingers and IP joint of both 1st fingers

REC) clinical correlation

Hallux angle

[Reading]
hallux valgus angle(normal<15degree)

Rt: degree

Lt: degree

calcaneal inclination angle(normal 18 to 30 degree)

Rt: degree

Lt: degree

Bunionette deformity, 5th MTP joint

[Conclusion]

hallux valgus deformity, both 1st MTP joint

Bunionette deformity, 5th MTP joint

REC) clinical correlation

Post op
[Reading]

S/P arthroscopic surgery

No significant unusual postoperative finding.

[Conclusion]

No unusual postop. finding.

CPA hidden

[Reading]

[Conclusion]

Addendum: cannot exclude hidden lesion at retrocardiac, both hilar, rib regions and diaphragm
area

Chest PA template

[Reading]

lung:

air way:

hilum:

aorta:

heart:

CPA, pleura:

rib:

clavicle, scapula:

spine:
upper abdomen:

chest wall/neck portion:

No definite active lung lesion

No cardiomegaly

[Conclusion]

No definite active lung lesion

REC) clinical correlation and F/U

Cardiomegaly

[Reading]

CT ratio is increased.

No defininite active lung lesion.

[Conclusion]

Cardiomegaly

REC) clinical correlation and consider EKG and echocardiography.

Cam type FAI

[Reading]

Femoral bump at both head to neck junction of both proximal femur

Degenerative change in both femoroacetabular joint

[Conclusion]

[Conclusion]

r/o Cam type femoroacetabular impingement, both

REC) clinical correlation

Bunion op

[Reading]

s/p bunionectomy

No definite abnormal post op finding

[Conclusion]

s/p bunionectomy

REC)clinical correlation and F/U

Arthroscopy

[Reading]

air density in suprapatellar pouch

-> arthroscopy related finding

No other remarkable change

[Conclusion]

air density in suprapatellar pouch

-> arthroscopy related finding

REC) clinical correlation and f/u

Arthro

[Reading]

Arthroscopy op state

No other significant change

[Conclusion]

Arthroscopy op state

REC) clinical correlation and F/u

Ankle soft tissue

[Reading]

soft tissue swelling around ankle,

no definite gross bony abnormality

[Conclusion]

soft tissue swelling around ankle,

REC) clinical correlation

Acromioplasty
[Reading]

s/p acromioplasty,

No other change

[Conclusion]

s/p acromioplasty,

REC) clinical correlation and f/u

Acetabular dysplasia

[Reading]

Undercoverage of femoral head by acetabulum, both

No definite bony fracture

[Conclusion]

mild acetabular dysplasia, both

REC) clinical correlation

No change

[Reading]

No significant interval change since last exam.

[Conclusion]

No significant change.
REC) clinical correlation and F/U

반전대조도,lytic, sclerotic, periosteal rx,

특히 fx 있는듯, 근데 pain 없으면 tumor 의심

vb anterior step defect

soft tissue mass

lung 있으면 꼭봐!! rib, clavicle frx 있는지!

free air!!

생길수 있는 최악의 상황은!

쪼금이라고 찝찝하면 다른사람한테 물어봐라!!

No gross bony abnormality

[Reading]

No gross bony abnormality.

[Conclusion]

No gross bony abnormality.

REC) clinical correlation

증상이랑 안맞으면 다른거의심, 특히 fx 인데 no pain

반전대조도,lytic, sclerotic, periosteal rx,

vb anterior step defect, sacrum

soft tissue mass

lung 있으면 꼭봐!!

rib, clavicle frx 있는지!

free air!!

생길수 있는 최악의 상황은!

쪼금이라고 찝찝하면 다른사람한테 물어봐라!!

No definite active lung lesion

[Reading]

No definite active lung disease.

No cardiomegaly.

[Conclusion]

No definite active lung disease.

checklist

lung base, lung apex with bone

trachea

rib(upper boder 안보이면 pathology)

aircrescent sign

foreign body

hilum, retrocardiac
pneumothorax, pneumomediastinum

free air

clavicle fracture

pedicle

paravertebra

REC) clinical correlation and regular F/U

Addendum: chest PA shows no definite active lung lesion, but cannot exclude of hidden lesion
at retrocardiac, both hilar, rib regions and diaphragm area, etc

C spine

[Reading]

ADI(atlantodental interval, normal<3mm):

OPLL:

Straightening of C spine curvature

-> r/o C sprain

prevertebral space

epiglottis

Degenerative spondylosis with disc space narrowing at c5-6

Diffuse uncovertebral joint hypertrophy

Suspected neural foraminal stenosis at Lt Rt

lung, rib, air way, soft tissue skull , lower face 확인

[Conclusion]

r/o C sprain

Degenerative spondylosis with disc space narrowing at c5-6

REC) clinical correlation consider C spine MR with T2 fat sat if clinically warranted.

L spine

[Reading]

Straightening of L spine curvature

Marginal osteophyte in spine.

Disc space narrowing at

T process, spinous proces, pedicle, pars, sacrum rib paraspinal and soft tissue check

Baastrup syndrome check(kissing spines)

[Conclusion]

r/o L spine sprain

Degenerative spondylosis with disc space narrowing at

REC) clinical correlation consider L spine MR with T2 fat sat if clinically warranted.

Shoulder

[Reading]

Shoulder x-ray

findings
No definite visible bony destruction

AC joint degeneration and glenohumeral joint degeneration

curved acromion

[Conclusion]

Degenerative change in shoulder joint, both

REC) clinical correlaton and F/U or if clinically needed, consider shoulder MR

Degenerative

[Reading]

degenerative change in

No definite bony fracture

[Conclusion]

degenerative change in

REC) cllinical correlation and F/U or further w/u

Clinical correlation

[Reading]
.

[Conclusion]

REC) clinical correlation

병변이 찾았어도 다른 병변 놓치지 않게 꼼꼼열심히!!

증상이랑 안맞으면 다른거의심, 특히 fx 인데 no pain

반전대조도,lytic, sclerotic, periosteal rx,

vb anterior step defect, sacrum

pedicle 이 intact 한지

soft tissue mass

lung 있으면 꼭봐!! rib, clavicle frx 있는지!

free air!!

생길수 있는 최악의 상황은!

쪼금이라고 찝찝하면 다른사람한테 물어봐라!!