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 and C Spine

Description: Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained.
(Medical Transcription Sample Report)

CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST

REASON FOR EXAM: Motor vehicle collision.

CT HEAD WITHOUT CONTRAST

TECHNIQUE: Noncontrast axial CT images of the head were obtained.

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. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear.

IMPRESSION: Negative for acute intracranial disease.

CT CERVICAL SPINE

TECHNIQUE: Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained.

FINDINGS: Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus.

IMPRESSION:
1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.
2. Degenerative disk and joint disease at C5-C6.
3. Retention cyst versus polyp of the right maxillary sinus.

Keywords: orthopedic, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast,
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