Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic
Sample Name: CT Head, Facial Bones, Cervical Spine - 1

Description: Motor vehicle collision. CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.
(Medical Transcription Sample Report)

CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST

REASON FOR EXAM: Motor vehicle collision.

CT HEAD

TECHNIQUE: Noncontrast axial CT images of the head were obtained without contrast.

FINDINGS: There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. No calvarial fracture is seen.

IMPRESSION: Negative for acute intracranial disease.

CT FACIAL BONES WITHOUT CONTRAST

TECHNIQUE: Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.

FINDINGS: There is no facial bone fracture. The maxilla and mandible are intact. The visualized paranasal sinuses are clear. The temporomandibular joints are intact. The nasal bone is intact. The orbits are intact. The extra-ocular muscles and orbital nerves are normal. The orbital globes are normal.

IMPRESSION: No evidence for a facial bone fracture.

CT CERVICAL SPINE WITHOUT CONTRAST

TECHNIQUE: Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.

FINDINGS: There is a normal lordosis of the cervical spine, no fracture or subluxation is seen. The vertebral body heights are normal. The intervertebral disk spaces are well preserved. The atlanto-dens interval is normal. No abnormal anterior cervical soft tissue swelling is seen. There is no spinal compression deformity.

IMPRESSION: Negative for a facial bone fracture.

Keywords: orthopedic, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones,
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