SYNTHETIC, DE-IDENTIFIED EXAMPLES

Sample reports that show how we think clinically.

Illustrative reporting examples demonstrating trauma prioritization, integrated grading, neutral personal-injury morphology, device attention, oncology staging, and actionable impressions.

RPT

5examples

QAfocused

SLAaligned

REPORTING PRINCIPLES

Clinical question first. Descriptive depth where it matters. Actionable impression at the end.

These examples are synthetic and contain no patient information. They illustrate report style rather than contractual turnaround or outcome guarantees.

Structured & Subspecialty

Anatomy-first findings with modality-appropriate staging, classification, and grading where supportable.

Critical Communication

Urgent findings are paired operationally with the facility's agreed critical-result notification workflow.

Actionable Impressions

Concise conclusions prioritize severity, acuity, and clinically relevant next-step information.

SAMPLE REPORTS

Five examples across common high-value teleradiology workflows.

CT Trauma

Polytrauma CT chest, abdomen and pelvis

STUDY:
CT Chest, Abdomen and Pelvis With IV Contrast

HISTORY:
High-energy blunt trauma with left upper quadrant pain and chest wall tenderness.

TECHNIQUE:
Contrast-enhanced CT of the chest, abdomen and pelvis with multiplanar reformations.

COMPARISON:
No prior studies available.

FINDINGS:
CHEST: Acute mildly displaced fractures of the left lateral sixth through ninth ribs. Small left hemothorax with adjacent dependent atelectatic change. No pneumothorax. No acute aortic injury. No mediastinal hematoma.

ABDOMEN AND PELVIS: Multifocal splenic lacerations measuring up to 3.6 cm depth without hilar involvement, active contrast extravasation, or devascularized segment. Small-volume perisplenic and pelvic hemoperitoneum. Liver, pancreas, adrenal glands, kidneys, and bowel show no acute traumatic injury. No free intraperitoneal gas. No acute pelvic fracture.

IMPRESSION:
1. Acute AAST grade III splenic injury with small-volume hemoperitoneum; no active extravasation.
2. Acute left sixth-ninth rib fractures with small left hemothorax; no pneumothorax.
3. No acute aortic, hepatic, renal, bowel, or pelvic traumatic injury.

CRITICAL RESULT WORKFLOW:
Synthetic example: findings of this severity would trigger immediate physician/facility notification per SLA.

MRI Lumbar Spine

Degenerative disease with integrated grading

STUDY:
MRI Lumbar Spine Without IV Contrast

HISTORY:
Low back pain with bilateral lower-extremity radicular symptoms.

TECHNIQUE:
Multiplanar multisequence MRI of the lumbar spine without intravenous contrast.

COMPARISON:
No prior studies available.

FINDINGS:
ALIGNMENT / MARROW: Mild grade 1 anterolisthesis of L4 on L5. Vertebral body heights maintained. No acute osseous abnormality.

CONUS: Terminates at L1. No abnormal cord or cauda equina signal.

L1-L2: Pfirrmann grade II disc. No significant canal or foraminal stenosis.

L2-L3: Pfirrmann grade III disc with mild circumferential bulge. Mild bilateral facet arthropathy. No significant central canal stenosis. Lee grade 1 bilateral foraminal stenosis.

L3-L4: Pfirrmann grade III disc with broad-based bulge and ligamentum flavum thickening. Schizas grade B central canal stenosis. Lee grade 1 right and grade 2 left foraminal stenosis.

L4-L5: Pfirrmann grade IV disc with broad-based disc protrusion, advanced facet arthropathy, and ligamentum flavum thickening. Schizas grade C central canal stenosis with bilateral lateral recess narrowing and contact/compression of the traversing L5 roots. Lee grade 2 right and grade 3 left foraminal stenosis with left exiting L4 root compression.

L5-S1: Pfirrmann grade IV disc with central/left paracentral protrusion contacting the traversing left S1 root. No significant central canal stenosis. Lee grade 2 bilateral foraminal stenosis.

IMPRESSION:
1. Severe L4-L5 central canal stenosis, Schizas C, with bilateral traversing L5 root compression.
2. Severe left L4-L5 foraminal stenosis, Lee 3, with exiting L4 root compression.
3. L5-S1 left paracentral protrusion contacting the traversing left S1 root.

Personal Injury / No-Fault MRI

Neutral morphology-focused cervical spine reporting

STUDY:
MRI Cervical Spine Without IV Contrast

HISTORY:
Neck pain and upper-extremity symptoms following motor vehicle collision.

TECHNIQUE:
Multiplanar multisequence MRI of the cervical spine without intravenous contrast.

COMPARISON:
No prior studies available.

FINDINGS:
ALIGNMENT / MARROW: Straightening of the cervical lordosis. Vertebral body heights maintained. No acute compression fracture.

CRANIOCERVICAL JUNCTION: Unremarkable.

CORD: Normal caliber and signal.

C2-C3: No focal disc herniation or significant stenosis.

C3-C4: Small central disc protrusion mildly indents the ventral thecal sac without cord deformation.

C4-C5: Broad-based posterior disc herniation, slightly left asymmetric, with mild ventral cord contouring. Mild central canal narrowing and moderate left foraminal narrowing.

C5-C6: Broad-based posterior disc herniation with annular fissure. Moderate central canal narrowing with mild ventral cord flattening. Moderate bilateral foraminal narrowing. No cord signal abnormality.

C6-C7: Left paracentral disc protrusion narrows the left lateral recess and mildly narrows the left neural foramen.

C7-T1: No focal disc herniation or significant stenosis.

IMPRESSION:
1. C5-C6 broad-based disc herniation with moderate canal and bilateral foraminal narrowing.
2. C4-C5 disc herniation with mild cord contouring and moderate left foraminal narrowing.
3. C6-C7 left paracentral protrusion with left lateral recess narrowing.

REPORTING NOTE:
Synthetic PI/no-fault example uses neutral imaging morphology without assigning causation or chronicity from MRI alone.

Portable Chest X-Ray

Device, line, tube and interval-change focused

STUDY:
Portable AP Chest Radiograph

HISTORY:
ICU patient after intubation and central venous catheter placement.

TECHNIQUE:
Single portable AP chest radiograph.

COMPARISON:
No prior studies available.

FINDINGS:
DEVICES: Endotracheal tube tip projects 4.2 cm above the carina. Enteric tube courses below the diaphragm with tip beyond the field of view. Right internal jugular central venous catheter tip projects over the lower superior vena cava. No postprocedural pneumothorax.

CARDIOMEDIASTINAL SILHOUETTE: Mild enlargement.

LUNGS / PLEURA: Mild bilateral perihilar and bibasilar interstitial-airspace opacities, compatible with pulmonary edema and dependent atelectatic change. Small bilateral pleural effusions.

OSSEOUS / SOFT TISSUES: No acute osseous abnormality identified on this single projection.

IMPRESSION:
1. Support devices positioned as described; no postprocedural pneumothorax.
2. Mild pulmonary edema with bibasilar atelectatic change and small pleural effusions.

Oncology Subspecialty MRI

Rectal cancer staging with actionable treatment-planning information

STUDY:
MRI Pelvis - Rectal Cancer Staging

HISTORY:
Biopsy-proven low rectal adenocarcinoma for local staging.

TECHNIQUE:
Dedicated high-resolution rectal MRI with multiplanar T2-weighted, diffusion-weighted, and post-contrast sequences.

COMPARISON:
No prior studies available.

FINDINGS:
TUMOR: Annular low rectal tumor centered 3.5 cm from the anal verge, extending over 4.2 cm craniocaudally. Tumor extends 8 mm beyond the muscularis propria into the mesorectal fat, consistent with mrT3c disease.

MESORECTAL FASCIA: Tumor margin 1 mm from the mesorectal fascia, compatible with threatened circumferential resection margin.

EMVI: Positive extramural venous invasion.

SPHINCTER COMPLEX: Internal sphincter involvement without external sphincter or levator invasion.

NODES: Multiple morphologically suspicious mesorectal nodes, largest 8 mm. Suspicious left obturator node measuring 1.1 cm.

ADJACENT ORGANS / PERITONEUM: No direct invasion of bladder, prostate/seminal vesicles, pelvic sidewall, or osseous structures. No pelvic peritoneal deposits.

IMPRESSION:
1. Low rectal carcinoma, mrT3c, mrN2, mrEMVI positive.
2. Threatened mesorectal fascia with 1 mm margin; internal sphincter involvement.
3. Suspicious left obturator nodal metastasis.
4. Multidisciplinary rectal oncology review recommended for treatment planning.

FACILITY-SPECIFIC REPORTING

We can align examples to your case mix and reporting expectations.

During onboarding, sample reports can be adapted to the facility's modalities, terminology, classifications, impression style, escalation rules, and workflow requirements.

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