How to report an ultrasound examination Jean Wilson University of Leeds School of Healthcare University of Leeds What is the question? Why is the ultrasound scan being undertaken? Rule in/out an abnormality What is the clinical question? Specific question or a vague impression The ultrasound examination Before the examination What is the clinical question During the examination Specific ultrasound observations After the examination Judgement / conclusions / report Making a decision Process of judgement : making a decision or conclusion on the basis of indications and probabilities Aim - to obtain information of a good predictive value Seeing pictures Interpreting an ultrasound examination To interpret : to translate something which is obscure or ambiguous into intelligible terms To judge : to form an opinion, to estimate, infer, conclude, arrive at a decision Seeing pictures CXR ? Normal /abnormal CXR – Observations CXR – Observations: Heart Mediastinum Lungs Bones Other CXR – Observations Absent clavicles cleidocranial dysplasia. This film illustrates the benefit of using a systematic approach in viewing images. A gross finding such as absent clavicles can be surprisingly easy to miss. Absent clavicles cleidocranial dysplasia Using words Descriptive statement : can be confirmed by reference to the image Inferential statement : involves extrapolation of information / evidence Observations / conclusions Making a list of observations may be useful as a process, but conclusions are usually required in an ultrasound diagnosis Ultrasound observations Location and size Internal characteristics Borders / outline Attenuating properties other features UKAS Guidelines The ultrasound report should be written by the person performing the ultrasound examination and should be viewed as an integral part of the whole examination. UKAS Guidelines The person issuing the report should take responsibility for the accuracy of the report. UKAS Guidelines Elements of a report Patient ID Examination performed Description of the findings Diagnosis or conclusion Answer the clinical question Recommendations for further investigations Date of examination and report Name and status of reporter Perception Observer error/variation ‘In judging a pair of films for evidence of progression, regression or stability of disease in patients with pulmonary tuberculosis, two readers are likely to disagree with each other in almost 33% of the cases and a single reader is likely to contradict himself in approximately 20% of cases’ Yerashalmy at al., 1951 Case study 35 year old Ultrasound of pelvis 2 Year history of cystitis Dyspareunia with tender uterus and adnexae Case study - the 4 reports The uterus and both ovaries were well visualised and were normal. No free fluid noted. The bladder was normal as were both kidneys. Normal appearances of anteverted uterus and both ovaries. No masses or free fluid seen. No hydronephrosis demonstrated. The uterus and both ovaries appear normal. No adnexal mass or cyst identified. No free fluid. The uterus and both ovaries were clearly identified. No abnormality demonstrated. No hydronephrosis. What is a good report? How do you measure this ? What do you measure it against ? How can you investigate the validity of the content of the report ? Is consensus the ‘gold standard’ ? Radiography reporting research GOLD STANDARD Agreement No.of Films Musculo-skeletal 200 Chest 100 Abdomen 100 Disagreement 90% 10% 59% 41% 52% 48% UKAS Guidelines Report style The style of the report should be concise, clear and easily understood. Potentially ambiguous phraseology should not be used. Irrelevant information should be avoided UKAS Guidelines Report style The practitioner should be aware of his/her limitations and consequently seek advice when necessary Abbreviations should only be used when the user is confident that they will be clearly interpreted UKAS Guidelines Technical language Acoustic or technical language should be used when it significantly assists in the diagnosis. UKAS Guidelines Limitations Any limitations should be stated and, if a relevant organ has not been fully examined, the reason(s) should be indicated The exclusion value and significance of the appearances should be stated where relevant. UKAS Guidelines Report example Referral for RUQ pain US report The liver has increased echogenicity with reduced prominence of portal tracts consistent with fatty change. There is a 3 cm highly reflective focal lesion in segment 6 of the liver. The appearances are typical of an haemangioma but if there is clinical suspicion of malignancy then metastasis cannot be excluded . Normal appearances of the gall bladder, pancreas, spleen and both kidneys. The negative examination ‘Normal’ ‘Appears within normal limits’ ‘No significant abnormality’ ‘Normal for age’ ‘Normal except for…’ ‘No evidence of…’ Radiologic Reporting : Structure American Journal of Radiology Friedman P J., 1983 Ending the report Impression – a vague or indistinct notion Opinion – what one thinks Summary – restatement in shortened form Conclusion – judgement or statement arrived at Diagnosis – clinician arrives at this Interpretation – meaningful appraisal of the data The language of certainty: proper terminology for the ending of the radiologic report AJR , Orrison W W., 1985 Report checklist Concise style No ambiguous phraseology No inappropriate technical language Irrelevant information avoided Limitations stated Report checklist Abbreviations used carefully Address the clinical question Conclusive where possible / alternative explanation of appearances Exclusion value / significance if relevant Thank you