Medical Specialty:
Neurology

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: neurology, 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,