These reports
are samples of basic clinical evaluations of patients seen by a radiologist. The sample reports have been checked for
accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample
medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference
of the dictating physician.
Edited Sample Reports CERVICAL SPINE
Degenerative disc disease is noted throughout the cervical spine, but is most severe from C4 to C7 inclusive.
Marked spur formation is noted to the intervertebral foramina bilaterally at these levels. No fracture or dislocation is identified.
THORACIC SPINE
The vertebral bodies have normal height and alignment and the discs are of normal width.
The pedicles and neural arches appear intact. LUMBAR SPINE
Since January of 1999, progressive degenerative changes have occurred on the left
side between the first and fourth lumbar vertebrae inclusive, slightly increasing the scoliosis convexity
towards the right. No fracture is identified.
Edited Sample Report
CHEST
The heart outline is normal and the hilar and mediastinal vessels are of normal appearance.
No disease is seen in the lung fields or pleura.
Edited Sample Report
ESOPHAGUS, STOMACH & DUODENUM
There was no abnormality in the lower oesophagus and no hiatus hernia was detected.
The stomach and duodenum appeared normal.
Edited Sample Report
CERVICAL SPINE
Long-standing and severe degenerative disc disease is noted at the C5-C6 level
with significant spur formation bilaterally into the intervertebral foramina. No fracture or dislocation
is observed.
Edited Sample Report
CHEST
Moderate eventration of the anterior portion of the right hemidiaphragm is present. Partial collapse
of the right middle lobe is identified and an unusual spherical density is seen over the apex of the right hemidiaphragm on
the PA projection.
A follow-up examination in 10-14 days is highly recommended.
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