第1章放射診斷學(xué)報(bào)告概要
　　Chapter 1Outline of Radiodiagnostic Report
　　第1節(jié)放射診斷學(xué)報(bào)告的書寫原則
　　Section 1The Writing Principle of Radiodiagnostic Report從事放射學(xué)診斷的醫(yī)生應(yīng)全面、客觀地依據(jù)患者的放射學(xué)所見(jiàn)，密切結(jié)合臨床和其他相關(guān)檢查，有時(shí)需要在親自檢查患者后才能作出判斷——放射學(xué)診斷。
　　以下幾點(diǎn)很重要：
　�。�1）以人體解剖學(xué)和生理學(xué)為基礎(chǔ)，熟悉正常放射學(xué)影像。
　�。�2）以病理學(xué)、醫(yī)學(xué)診斷學(xué)和放射診斷學(xué)為基礎(chǔ)，認(rèn)識(shí)異常放射學(xué)影像。
　�。�3）結(jié)合臨床檢查、實(shí)驗(yàn)室檢查和其他醫(yī)學(xué)影像學(xué)檢查結(jié)論及治療經(jīng)過(guò)，還要考慮檢查部位、體位、技術(shù)、方法和設(shè)備等方面的因素，養(yǎng)成全面觀察和綜合分析的良好習(xí)慣，才能得出可靠的結(jié)論——放射學(xué)診斷。
　　The radiologist should make rational and reliable conclusion（s）radiodiagnosis（readiodianoses），based on the combination of radiodiagnostic findings with the clinical data and the other related and corresponding tests，sometimes examining the patient in detail personally.
　　The following are essential in radiodiagnosis（radiodiagnoses）.
　�。�1）Normal radiodiagnostic findings are familiarized on the basis of anatomy and physiology of the human body.
　　（2）Abnormal radiodiagnostic findings are identified in accordance with the knowledge of pathology，medical diagnostics and radiodiagnostics.
　�。�3）The radiodiagnostic findings should be combined with the clinical symptoms and signs，results of laboratory tests and other medical imaging information，and therapeutic effectiveness to make a reliable diagnosis.Meanwhile，all technical factors in the examination should be taken into consideration，such as postures，views，regions of the body，examination techniques and imaging equipment.Only through cultivating a good habit of analyzing radiographs in a certain order and interpreting the radiological findings as an interrelated whole，then，can the radiologist reach reliable conclusion（s）.
　　第2節(jié)放射診斷學(xué)報(bào)告的書寫方法
　　Section 2The Writing Method of Radiodiagnostic Report
　　放射學(xué)診斷一般采取先定位、定量，后定性的方法，前二者是條件，后者是結(jié)論。觀察每幅圖像，首先要了解它的技術(shù)條件，然后按一定順序，如從患者圖像的右側(cè)至左側(cè)，從上方至下方詳細(xì)觀察、對(duì)比、全面分析，特別注意不要遺漏圖像邊緣的病變。
　　The tasks of radiodiagnosis are intended to resolve 3 questions which are localization，quantification and characterization of lesion（s）.The first two steps are prerequisites and the final step leads to diagnosis（or diagnoses）.For each radiograph，technical factors are considered firstly.Then，careful observations will be explored from the right to the left of an image of a patient，from upward to downward. Following that，the radiologist should have a comprehensive and reasonable analysis（analyses）. Be sure，nothing is ignored especially in the margins of images.
　　1.病變的分布
　　有些病變常好發(fā)生于人體的某個(gè)（些）部位，病變分布有一定的規(guī)律性，如在范圍上呈廣泛性或局限性分布；在結(jié)構(gòu)上呈散在性分布或密集性分布。
　　2.病變的數(shù)目和大小
　　常與病變的性質(zhì)有關(guān)。
　　3.病變的形狀與邊緣
　　邊緣模糊的片狀影常為急性滲出性炎癥；邊緣整齊的條帶影常為慢性增殖性病變。
　　4.病變的密度
　　與周圍正常組織對(duì)比，病變的密度增高、減低或相同。
　　5.病變周圍組織
　　有無(wú)“衛(wèi)星”病灶；病變周圍的結(jié)構(gòu)有無(wú)改變。
　　1.Distribution of lesions
　　Some diseases often predispose in a certain part（parts）of the human body.There are some rules of thumb for them.Distributions of lesions are depicted as an extensive or localized range，scattered or dense structure.
　　2.Numbers and sizes of lesions
　　These often relate to the characterization of lesions.
　　3.Shapes and margins of lesions
　　A fuzzy margin on a patchy shadow often represents an acute inflammation，while a clear margin in a stripelike substance usually suggests a chronic proliferation.
　　4.Changes in density
　　In comparison with the normal surrounding tissues，lesions are described as high density，low density or isodensity.
　　5.Surrounding tissues
　　It is important to verify whether there are scattered “satellite”foci and alterations of the surrounding structures.
　　第3節(jié)放射診斷學(xué)報(bào)告的結(jié)構(gòu)
　　Section 3The Structure of Radiodiagnostic Report
　　放射診斷學(xué)報(bào)告是放射科醫(yī)師的會(huì)診意見(jiàn)，應(yīng)高度重視。它作為醫(yī)療記錄的一部分，也是醫(yī)療訴訟的依據(jù)。所以要用詞準(zhǔn)確、恰當(dāng)，層次清楚，分析合理，決不能草率從事。放射診斷學(xué)報(bào)告應(yīng)包括以下內(nèi)容：基本信息、描述部分、診斷部分和醫(yī)師簽名。
　　1.基本信息
　　包括患者的姓名、年齡、性別；X線檢查號(hào)、CT檢查號(hào)、MRI檢查號(hào)、DSA檢查號(hào)、住院號(hào)、門診號(hào)；X線檢查日期，CT檢查日期，MRI檢查日期，DSA檢查日期；檢查部位；X線投照體位（常見(jiàn)的有后前位攝片，前后位攝片，左側(cè)位攝片，右側(cè)位攝片，左前斜位攝片，右前斜位攝片等）；送檢科室和臨床診斷，這些基本信息可以在PACS上與登記處共享。
　　2.描述部分
　　一般按攝片的部位、范圍，受檢器官的組織結(jié)構(gòu)順序進(jìn)行描述。當(dāng)發(fā)現(xiàn)病變時(shí)，按先重后輕，先因后果，用X線術(shù)語(yǔ)描述，避免診斷用語(yǔ)，如膿腫或骨折等。
　　The writing of radiodiagnostic report has to be a precise work because it is not only a consulting suggestion for clinicians but also a medicolegal document.The radiologist should choose words carefully and correctly and try to make the report in clarity of description and a reasonable analysis.Carelessness should always be avoided at any condition.A radiodiagnostic report should include the following items: basic information，description，diagnosis（or diagnoses）and signature of the radiologist（s）.
　　1.Basic Information
　　Filling out the header line by line，such as Name，Age，Sex of the patient；Number of Xray examination，Number of CT examination，Number of MRI examination，Number of DSA examination，Number of inpatient，Number of outpatient；Date of Xray examination，Date of CT examination，Date of MRI examination，Date of DSA examination；Regions of examinations；Views of radiographs（including Posteroanterior（PA）view，Anteroposterior（AP）view，Left Lateral（LL）view，Right Lateral（RL）view，Left Anterior Oblique（LAO）view，Right Anterior Oblique（RAO）view，and etc）；referring department of the patient and the clinical diagnosis（or diagnoses）.These data can