A radiology report is a written document created by a radiologist, a medical doctor specializing in medical imaging, after reviewing a patient’s images (such as X-rays, CT scans, or MRIs). This report serves as a formal consultation between the radiologist and the referring physician, translating visual information into a structured, textual analysis. For patients accessing their medical records, the dense medical language and standardized format can be confusing. Understanding the organizational framework and specific terminology of these reports can empower patients to engage more fully in discussions about their health and treatment options.
The Essential Components of a Radiology Report
The first part of any report contains administrative and logistical information that establishes the context for the medical findings. This section often includes your personal demographics, such as your name, date of birth, and medical record number. It also lists the specific details of the study performed, including the type of imaging modality (like an X-ray or MRI) and the exact date and time the examination took place.
The “Clinical Indication” section explains the reason the test was ordered, such as “persistent headache” or “evaluation of a suspected fracture.” This information provides the radiologist with the clinical question they are attempting to answer, guiding their interpretation. If you have had previous imaging, the “Comparison” section will list the dates and types of those prior studies. Comparing current images to past ones is standard practice for tracking disease progression or stability.
Deciphering the Findings and Impression Sections
The core of the report is divided into two distinct sections: the objective observations and the interpretive summary. The “Findings” section provides a detailed, objective description of everything the radiologist saw in the images. This descriptive account focuses on the appearance, size, and location of both normal structures and any detected abnormalities, using precise anatomical terminology. For example, it might note the presence of a “5mm calcification” or a “density in the upper lobe of the left lung.”
Following the detailed description is the “Impression” or “Conclusion” section, which is the radiologist’s professional opinion and synthesis of the findings. This section distills the raw data into a concise summary of the most significant observations. The Impression is often the most relevant section for the patient because it typically addresses the clinical question posed in the Indication. It may also list a differential diagnosis, which is a list of possible causes for the findings.
Common Terminology and Medical Jargon Explained
Radiology reports employ specific terminology. The term “unremarkable” or the abbreviation “WNL” (Within Normal Limits) means the radiologist found no abnormal or concerning findings in the area examined. When describing images from a CT scan, “attenuation” describes how much the tissue blocked the X-ray beam, similar to density. Tissues that block more radiation are high-attenuation (like bone), while air or fluid are low-attenuation.
In descriptive terms, “lucency” refers to an area that appears darker on an X-ray or CT scan, often indicating air or fluid. Conversely, a “density” or “opacity” refers to a whiter area, suggesting a solid structure or increased tissue mass. When describing a mass or organ, “homogeneous” means the texture appears uniform throughout, while “heterogeneous” indicates a varied or mixed appearance. A recommendation to “compare to prior” studies means reviewing past images is necessary for an accurate assessment of stability or change. If the report suggests “follow-up recommended,” this instructs the referring physician that the finding is suspicious or requires monitoring over time.
Next Steps After Reviewing the Report
The radiology report is primarily a consultation tool written by one physician for another, not directly for the patient. The radiologist interprets the images, but the referring physician integrates those findings with your medical history, physical examination, and laboratory results to form a final diagnosis. Reading the report before speaking with your doctor can lead to premature conclusions or unnecessary anxiety due to the medical jargon.
The most constructive step after reviewing your report is to contact the healthcare provider who ordered the exam to schedule a discussion. Your referring physician is best equipped to interpret the report in the context of your overall health and clinical picture. During this appointment, ask your doctor to clarify any confusing terminology or complex findings, and to explain how the results affect your treatment plan and prognosis.