🩻Rédaction de comptes rendus d'imagerie médicale (radiologie, scanner, IRM) en anglais

Chapitre 1 / 425%

📋

Structure & standard phrases

The Radiology Report: An Overview

A radiology report is a formal medical document describing imaging findings. In English-speaking hospitals, reports follow a standard structure: clinical history, technique, findings, and impression. Clear, concise language avoids ambiguity. For example, 'No acute intracranial hemorrhage' is stronger than 'no bleed seen'. Use standard terms like 'unremarkable' for normal.

📖 Définition

Unremarkable: normal, no significant abnormality seen.

⭐ À retenir

Always start with the clinical question; it guides the whole report.

💡 À retenir : A structured report = clinical history + technique + findings + impression.

Complète la phrase

The report begins with the patient's and the imaging used.

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Key vocabulary & patterns

Describing What You See

Use standard terms: 'opacity' for X-ray, 'attenuation' for CT, 'signal intensity' for MRI. Describe location using anatomical terms such as 'right upper lobe' or 'left lower quadrant'. For abnormalities, specify size, shape, and margins, for example 'a 2-cm well-circumscribed nodule'. Compare with previous exams when possible, writing 'stable since prior study'.

🔍 Exemple

A 3-cm spiculated mass in the right upper lobe concerning for malignancy.

📖 Définition

Attenuation: degree of X-ray absorption on CT (hypodense, isodense, hyperdense).

💡 À retenir : X-ray: opacity; CT: attenuation; MRI: signal intensity.

✅

From findings to diagnosis

The Impression Section

The impression is the most read part of the report. Start with the most important finding, then list differential diagnoses. Use phrases like 'most likely represents', 'cannot exclude', and 'correlate clinically'. Avoid absolute statements; prefer 'suspicious for' or 'consistent with'. If normal, write 'No acute findings' or 'Normal study'.

⭐ À retenir

Never write 'no pathology' alone; specify e.g. 'no acute cardiopulmonary findings'.

🔍 Exemple

Impression: 1. Right upper lobe consolidation, most likely pneumonia. 2. No pleural effusion.

💡 À retenir : Impression = ranked differential + recommendation.

⚠️

Avoiding errors

Quality and Clarity

Avoid vague terms such as 'some', 'a little', or 'maybe'. Do not use abbreviations without defining them first in the report. Proofread for grammar and spelling; a missed 'not' can change the meaning completely. Use active voice: 'The radiograph shows...' rather than 'It is shown that...'. Ask a peer or supervisor to review ambiguous reports.

📢 Rappel

In English medical writing, avoid contractions (don't, can't).

⭐ À retenir

Read the report aloud to catch missing negatives.

💡 À retenir : Precision prevents patient harm.

Fiche de révision Exercices

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