Sample Reports

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.