Summary and Report
| A concise summary should include identifications, radiological findings, localization, analysis, and conclusions. Positive findings and significant negatives should be reported. Here is an example. |
This is a CT scan of the head made on July 18, 20XX for Mr X, who is a 34 year old man. Transaxial cuts in 4mm slices extend from the foramen magnum to the vertex. Plain and enhanced views with brain and bone windows are included. Radiological findings include bilateral mildly enlarged frontal horns, as well as small gyri and widened sulci at the frontal poles more on the right than the left. In the clinical context of moderate head injury 2 months ago, these findings suggest post-traumatic atrophic changes. There are no signs of hematoma formation or of hydrocephalus. More detail might be shown in an MRI scan.