Sample Type / Medical Specialty: Orthopedic Description: CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.
Sample Name: CT of Lumbar Spine w/o Contrast
(Medical Transcription Sample Report)
EXAM: Lumbar spine CT without contrast.
HISTORY: Back pain after a fall.
TECHNIQUE: Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.
FINDINGS: There is no evidence for acute fracture or subluxation. There is no spondylolysis or spondylolisthesis. The central canal and neuroforamen are grossly patent at all levels. There are no abnormal paraspinal masses. There is no wedge/compression deformity. There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.
Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated. There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.
1. No evidence for acute fracture or subluxation.
2. Mild degenerative changes.
3. Probable left simple renal cyst.
orthopedic, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast,
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.