Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurology
Sample Name: CT Lumbar Spine - 2

Description: This is a middle-aged female with two month history of low back pain and leg pain.
(Medical Transcription Sample Report)

This is a middle-aged female with two month history of low back pain and leg pain.

FINDINGS:
Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.

Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.

L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).

L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).

L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).

L4-5: There is normal disc height, minimal anterior end plate spondylosis, and posterior non-compressive annular disc bulging. There is minimal narrowing of the lateral recesses of L5, mild to moderate facet arthrosis greater on the right, normal central canal and intervertebral neural foramina (image #35).

L5-S1: There is severe loss of disc height with vacuum change, spondylolisthesis with 6.9mm of anterolisthesis of L5 with no disc protrusion. There is mild to moderate neural foraminal stenosis with possible neural impingement greater on the right with elongation of the neural foramina, mild facet arthrosis, and moderate degenerative change at the level of the pars interarticularis defect. Normal central canal (image #39, 40, 42).

There is no significant degenerative change at the SI joints.

There is moderate arteriosclerotic calcifications in the abdominal aorta and proximal common iliac arteries.

IMPRESSION:
T11-12, T12-L1 anterior end plate spondylosis.

L1-2 anterior end plate spondylosis, and very minimal vacuum change within the disc space.

L2-3 loss of disc height, anterior end plate spondylosis, circumferential disc protrusion, right extraforaminal osteophyte disc complex, non-displaced right neural foraminal narrowing, and facet arthrosis.

L3-4 anterior end plate spondylosis, circumferential non-compressive annular disc bulging, facet arthrosis, with vacuum change on the right and non-compressive right neural foraminal narrowing.

L4-5 anterior end plate spondylosis, posterior annular disc bulging, facet arthrosis and narrowing of the lateral recesses of L5.

L5-S1 Grade I spondylolisthesis, advanced degenerative disc disease with vacuum change, neural foraminal stenosis possibly impinging exiting L5 nerve roots, degenerative change at the level of the pars interarticularis defect and facet joints.

Arteriosclerotic vascular calcifications.



Keywords: neurology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples