Radiography · Referral letter · Intermediate

OET Case Notes: Radiography — Chest CT Findings Report (Intermediate)

A radiographer reports CT chest findings to a referring respiratory consultant for a 62-year-old ex-smoker with an incidental 12 mm solitary pulmonary nodule. The intermediate challenge: translating technical imaging findings into concise clinical language, selecting what matters for the consultant's decision, and framing a recommendation without exceeding the radiographer's clinical scope.

Letter type

Referral

Write to

Referring Consultant (Respiratory Physician)

Target length

200–230 words

The case notes

Patient: Mr David Morrison, 62 years old

Reason for CT: Incidental 12 mm pulmonary nodule on chest X-ray during pre-operative assessment

Scan performed: CT thorax with contrast (2 mm slice thickness)

Right upper lobe: 12 × 10 mm soft tissue nodule, well-defined margins, non-calcified, no satellite nodules; Fleischner category CT-2

Hilar/mediastinal nodes: No pathological lymphadenopathy

Lung parenchyma: Background centrilobular emphysema bilaterally, consistent with smoking history; no consolidation, pleural effusion, or pneumothorax

Clinical history: Ex-smoker (30 pack-years, quit 8 years ago); no haemoptysis, weight loss, or systemic symptoms

Impression: Indeterminate 12 mm RUL nodule; malignancy cannot be excluded; surveillance recommended

Writing task

Write a report letter to referring consultant Dr Claire Nguyen summarising the CT chest findings, your impression, and your recommendation for follow-up.

What to include, what to cut

The hardest mark to win is selection. The same case notes contain decision-relevant facts and distractors. Here is what an examiner expects to see in a Grade B letter for this scenario, and what should be left out.

Include

  • The nodule's size, location, and key characteristics (margins, calcification)

    These are the decision-relevant imaging features. The consultant needs them to classify risk and plan follow-up. Size without location or margin detail is incomplete.

  • The Fleischner category and recommended follow-up interval

    Using the Fleischner classification frames the recommendation within an evidence-based guideline, which is expected in a radiography report letter.

  • The background emphysema with reference to the smoking history

    Incidental findings relevant to the clinical background must be included. Emphysema in a 30-pack-year ex-smoker is clinically significant and contextualises nodule risk.

Leave out

  • Technical imaging parameters beyond slice thickness (kV, mA, dose report)

    These belong in the technical record, not the clinical letter. The consultant needs findings and recommendations, not radiation physics.

  • Listing all normal structures

    Mention normal structures only if the clinical question required their exclusion. Listing everything normal pads the letter without adding clinical value.

Criterion in focus · Conciseness & Clarity

Radiology report letters are among the most concise in clinical correspondence. The examiner penalises redundancy: '12 × 10 mm well-defined non-calcified nodule' carries the same information as a much longer description in 40% of the words. Every adjective must earn its place. If removing it would not change the consultant's decision, cut it.

Now write the letter — and find out what is blocking your Grade B

Write a 200–230 words referral letter from these notes, paste it into the free checker for an instant read, then submit it for a human grade against all six criteria. Dr Mariam's team returns line-by-line feedback, from $12.

Questions about this case note

Can a radiographer make a clinical recommendation in an OET letter?
Yes — recommending follow-up imaging or further investigation is within the radiographer's professional scope. Frame it as: 'surveillance CT in 6 months is recommended per Fleischner Society guidelines'. What you avoid is a diagnostic conclusion (e.g. 'this is likely malignant') — that is the clinician's role.
How do I handle diagnostic uncertainty in a report letter?
State it precisely: 'malignancy cannot be excluded' is the standard phrase for an indeterminate nodule. Vague hedging ('this may or may not be significant') drops the Genre & Style mark by failing to meet professional reporting conventions.

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