Writing a good request

If imaging is needed, then it is important that the radiologist has the relevant clinical information to properly interpret the image. Always state the age, gender and relevant medical history (including past operations, illnesses, and malignancies) of the patient. Also state the significant findings from the patient interview in regard to the chief complaint (duration, location, etc.) and relevant findings from the corresponding review of systems. State the relevant findings from the physical examination, laboratory findings, and relevant findings from other complete examinations (e.g. endoscopy). Formulate a clear question so that the radiologist can better understand the clinical picture and what you want to rule in or rule out based on the history, the physical examination, lab findings, and the general appearance of the patient. Abnormalities may resemble each other in radiological images and if the relevant clinical information is not included than there is an increased chance the images will be misinterpreted.

 

Case 1 (fig. 13) is a 50 yo man with a cough, fever, and a CRP of 140 nmol/L (14.7 mg/L). Case 2 (fig. 14) is a 50 yo old man who smokes, has a cough and weight loss, but no fever or increased infection parameters. The images have similarities, but the clinical information helps the radiologist place the findings in the proper clinical context.

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Lobar pneumonia on a chest X-ray.
Lobar pneumonia on a chest X-ray.

Figure 13. X-thorax. Lobar pneumonia in the right upper lobe.

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Long tumor on a chest X-ray
Long tumor on a chest X-ray

Figure 14. X-thorax. Long tumor of the right lower lobe.

Important to note: Do not forget possible allergic reaction to iodinated contrast (especially with CT scans) and make sure to check kidney function if ordering a CT with IV contrast. With MRI requests you must mention the presence of prostheses, pacemakers, etc. and whether the patient is at risk for metal foreign objects in the eye (for example specific professions such as welders). Further, it is important to ask if the patient suffers from claustrophobia. Make sure that the investigation request remains legible. That it is complete, but also concise. In particular, omit information that is not relevant to the investigation. Avoid rare or specialty specific abbr1.

Example of a proper investigation request:

Clinical Picture:
PMH: 2008 cholecystectomy
HPI: 43 yo man. LRQ pain since yesterday. N/V and LOA present. No measured fever.
PE: RLQ rebound tenderness. Guarding.
Labs: Leuk 13, CRP 45. Urine: no abnormalities.

Requested Investigation:
Abdominal US

Question:
Appendicitis?

1 abbr: abbreviations

Poor example of a request:

Clinical Picture:
64 yo man who presented with liver mets KRAS+ from left sided colonic carcinoma. Patient presents after 6 courses capecitabine/oxiplatin with maintenance therapy (maintenance since August 2016). Good response to date. 
Due to HFS, capecitabine has been reduced to 50%. Since initiation of chemotherapy memory disorders have increased. Analysis by neurologist showed no evidence of underlying pathology. Since April 2017 patient has suffered from diplopia, MRI shows muscle atrophy with no underlying pathology, no mets. Is on a waiting list for strabismus surgery.
In August 2017 from a second opinion from the USA with possibility of surgical treatment. After consultation it was decided to not continue with this. In May 2018 it was discussed that terminating maintenance therapy was an option with the positive course. However, until now maintenance therapy has been continued on request of the patient.
Patient is still responsive to treatment after a year and a half of therapy with capecitabine/avastin Comes today for the 36th maintenance course. Primary resection after was the 35th treatment.

Question:
Evidence of metastasis? Please compare with CT from Nov 2018.

The request should be as follows:

Clinical Picture:
64 yo man with descending colonic carcinoma and metastasis to the liver. Good response to chemotherapy. Since around 1.5 years maintenance therapy with maintained sensitivity. Recent resection of primary colonic tumor (nov 2018).

Question:
Presence of new metastasis/progression of carcinoma?