- Your report for each of the reporting session cases should follow a standard format. This will aid the structuring of your report and its marking by the examiners. You are strongly advised to base the format of your report on the guidance given in this document. Points can be made in bullet point or long hand form - see the two specimen reports later in this document.
- You should strive to make your reports succinct and relevant.
- There is no need to list dates of investigations or to list all sequences unless these factors are of direct relevance. Similarly, there is no need to repeat the clinical information that has been given to you but you should use the clinical information in interpreting your observations.
- You will be penalised for incorrect statements and suggestions. You will also be penalised if you recommend inappropriate further investigations and management and show a lack of discrimination in your conclusions.
RECOMMENDED REPORT FORMAT
In this section, you should record your observations on the films from all the imaging studies available to you, including relevant positive and negative findings.
Here you should state your interpretation of the observed findings; for example, describe whether the mass or process you observe is benign, malignant or infective rather than neoplastic, giving your reasons.
- Main or Principal Diagnosis
Based on your interpretation you should attempt to come to a single diagnosis. If this is not possible, then state here which diagnosis you feel is most likely and then list other possibilities, in order of likelihood, in the differential diagnosis section.
- Any Differential Diagnoses
For some cases there will be no differential diagnoses; in others you may feel that you wish to include a few. These should be limited in number and brief. In your report you should indicate why you feel these were less likely than your main or principal diagnosis.
- Any Relevant Further Investigations or Management
In this section you should indicate any further appropriate investigations or clinical management. For example, if you diagnose a patient with a sub-dural collection then urgent referral is needed if there is evidence of brain compression. Similarly, if you make a diagnosis or an abscess or tumour, indicate if a drainage or biopsy is appropriate.
Case 1: A ten month old child seen unconscious in the A&E Department
Observations & Interpretation:
- A non-contrast head CT shows an extra-axial fluid collection on the left side of the brain. The shape of this suggests that it lies within the sub-dural rather than the sub arachnoid space. It contains both high and low attenuation material indicating that it is likely to represent an acute on chronic sub-dural haematoma. Midline shift is seen with compression of the left lateral ventricle. No skull fracture is seen on these images.
- A chest x-ray shows fractures of the left sixth and seventh ribs posterolaterally with evidence of callus formation indicating healing. There are also fractures of the right eighth and tenth ribs posteriorly but no associated callus or periosteal new bone, suggesting that these fractures have occurred very recently. These findings suggest that these rib fractures have occurred at different times. The lung fields are clear.
Principal diagnosis: non-accidental injury
Differential diagnosis: Consider accidental trauma. This appears unlikely in view of the posterior rib fractures of different ages.
Management: The patient needs an urgent neurosurgical opinion and the child protection service must be alerted. A skeletal survey should be performed to look for other fractures and to ensure that there is no evidence of any other skeletal abnormality, such as osteogenesis imperfecta.
Case 2: A two year old child with a painful left hip
Observations on abdominal radiograph
- lytic ill defined lesion left femoral neck with associated periosteal new bone formation
- calcification in the right upper quadrant
- possible paravertebral mass around the L1 vertebral body
Observations on skeletal scintigram (bone scan)
- Areas of increased uptake in the left 6th, 7th and 8th and the right 4th, 5th and 8th ribs, right humerus and left femur
- possible areas of increased activity in region of calcification seen on abdominal radiograph
- The lesion in the left femoral neck has the appearances of an aggressive lesion suggestive of malignancy. Infection appears unlikely.
- The calcification in the right upper quadrant could relate to the liver, gall bladder, kidney or adrenal gland. In the context of possible malignancy, this is likely to relate to a malignancy in the adrenal gland.
- The possible paravertebral soft tissue mass will need further investigation with cross sectional imaging but may indicate intraspinal extension of an adrenal tumour.
- The areas of increased activity on the bone scan suggest widespread skeletal metastases.
- Neuroblastoma in right adrenal region with bone involvement and possible intraspinal extension
- Adrenal carcinoma can rarely occur in this age group and may calcify but is unlikely to extend intraspinally.
- Wilms' tumour is intrarenal, only occasionally calcifies and rarely metastasises to bone so should not give these appearances.
Published: August 2005
- An ultrasound scan would confirm whether the calcified mass lies within the adrenal gland.
- An MRI scan, MIBG and skeletal scintigrams would be required for staging and monitoring response to treatment.
- Bone marrow aspiration and catecholamine estimation are usually also performed.
- A biopsy may also be required.