Normal descriptive phrases and full templates. Use them as a starting point and adapt to each case.
XR Chest radiograph (PA/lateral)
Descriptive phrases (normal)
Lungs
Lungs are well expanded and clear, without consolidation, effusion or pneumothorax.
Mediastinum & hila
Mediastinal contours and hila are normal. Trachea is midline.
Heart
Cardiac silhouette is normal in size and configuration.
Bones & soft tissues
Visualised osseous structures and soft tissues are unremarkable.
Full report template
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS:
Lungs are well expanded and clear, without consolidation, effusion or pneumothorax.
Mediastinal contours and hila are normal; trachea is midline.
Cardiac silhouette is normal in size.
Visualised bones and soft tissues are unremarkable.
IMPRESSION:
No acute cardiopulmonary abnormality.
Liver is normal in size and echotexture, without focal lesions. Intrahepatic bile ducts are not dilated.
Gallbladder & biliary tree
Gallbladder is normal, with thin walls and no calculi. Common bile duct is of normal calibre.
Pancreas
Pancreas, where visualised, is normal; the duct is not dilated.
Kidneys
Both kidneys are normal in size with preserved corticomedullary differentiation, without hydronephrosis or calculi.
Spleen & aorta
Spleen is normal in size. Abdominal aorta is of normal calibre.
Full report template
TECHNIQUE: Transabdominal ultrasound after fasting.
FINDINGS:
Liver normal in size and echotexture, no focal lesion; intrahepatic ducts not dilated.
Gallbladder normal, no calculi; CBD normal calibre.
Pancreas (visualised portion) normal.
Kidneys normal bilaterally, no hydronephrosis or calculi.
Spleen normal; aorta normal calibre. No free fluid.
IMPRESSION:
Normal abdominal ultrasound.
No acute territorial infarct, intracranial haemorrhage or mass effect. Grey–white differentiation is preserved.
Ventricles & spaces
Ventricular system and sulci are normal for age. No midline shift.
Bones & sinuses
No fracture. Paranasal sinuses and mastoids are clear.
Full report template
TECHNIQUE: Non-contrast axial CT of the head.
FINDINGS:
No acute infarct, intracranial haemorrhage, extra-axial collection or mass effect.
Grey–white differentiation preserved; ventricles and sulci normal for age; no midline shift.
No fracture; visualised paranasal sinuses and mastoids are clear.
IMPRESSION:
No acute intracranial abnormality.
Normal lumbar alignment. Vertebral body marrow signal is preserved.
Discs
Intervertebral discs show preserved height and hydration, without herniation.
Canal & foramina
Central canal and neural foramina are patent at all levels. No nerve root compression.
Conus
Conus medullaris terminates at a normal level and is of normal signal.
Full report template
TECHNIQUE: Multiplanar multisequence MRI of the lumbar spine without contrast.
FINDINGS:
Normal alignment; preserved vertebral marrow signal.
Intervertebral discs with preserved height and hydration; no herniation.
Central canal and neural foramina patent at all levels; no nerve root compression.
Conus medullaris normal in position and signal. No paraspinal abnormality.
IMPRESSION:
Normal lumbar spine MRI.