Radiology Report Disc Explained for Students (Easy Guide)

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Original Question

Radiology Report, Disc Repair LOCATION: Inpatient, Hospital PATIENT: Sara Vasek ATTENDING PHYSICIAN: Timothy Pleasant, MD RADIOLOGIST: Grey Lonewolf, MD EXAMINATION OF: Four lumbar films for lumbar laminectomy CLINICAL SYMPTOMS: Disc herniation FOUR LUMBAR FILMS FOR LUMBAR LAMINECTOMY: FINDINGS: No comparisons. On the image labeled #1, there is a metallic marker seen posteriorly at the L2 (second lumbar vertebra) level superior endplate, assuming there are five lumbar-type vertebral bodies. On the image labeled #2, there is a metallic density seen posteriorly with the thin metallic rod pointing at the L1 level and the other metallic hardware at the L1-2 level. On the film labeled #3, a posterior metallic hardware is again noted. The most cephalad metallic density is at the L2-3 level, and the thinner caudal metallic density is at the L3-4 level. Film labeled #4 demonstrates metallic densities, and they are located at the L1-2 and L4-5 levels. SERVICE CODE(S): ______________________________________ ICD-10-CM DX CODE(S):

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