NTE|1||
NTE|2|| * * * PRELIMINARY REPORT * * *
NTE|3||
NTE|4|L|Patient Name: Elation, Test Patient
NTE|5|L|Patient DOB: Apr 27, 1960
NTE|6|L|Patient MRN:
NTE|7|L|Ref. Physician: John,Doctor MD
NTE|8|L|Exam Date: May 19, 2014
NTE|9||
NTE|10||Basic Information
NTE|11||Time seen: Provider Initial Contact Time
NTE|12|| 09/18/2016 13:05.
NTE|13||History source: Patient, mother.
NTE|14||Arrival mode: Private vehicle.
NTE|15||History limitation: None.
NTE|16||Additional information: Chief Complaint (ST)
NTE|17||Chief Complaint ED: c/o fever x 2 days, h/o colitis. c/o NVD 09/18/16 12:55.
NTE|18||
NTE|19||History of Present Illness
NTE|20||The patient presents with abdominal pain and diarrhea. 14 year old
female with history of colitis, treated at LPCH, presents today for abdominal
pain, N/V/D since yesterday. Dr. Bass (pediatric gastroenterologist) at LPCH is
currently out of town. She was diagnosed with colitis in 8/16 and was placed on
long term oral prednisone as well as mesalamine. Pt states that she chronically
has diarrhea due to the colitis history but the N/V and abdominal pain are new
complaints.
NTE|21||
OR
NTE|1|L|Patient Name: Elation, Test Patient
NTE|2|L|Patient DOB: Apr 27, 1960
NTE|3|L|Patient MRN:
NTE|4|L|Ref. Physician: John,Doctor MD
NTE|5|L|Exam Date: May 19, 2014
NTE|6|L|
NTE|7|L|It is a Test result from Elation result interface.
NTE|8|L|
NTE|9|L|Please contact your vendor for Order provider and other setup.
NTE|10|L|
NTE|11|L|Test Exam # 7588125 - May 19 2014 - MRI - LUMBAR SPINE W/O \T\ W CONTRAST
NTE|12|L|Exam Performed at SimonMed Mesa Desert Campus
NTE|13|L|
NTE|14|L|CLINICAL INFORMATION
NTE|15|L|
NTE|16|L|Radiculopathy. Low back pain and left leg pain since October 2013. Prior lumbar
NTE|17|L|surgery October 2013.
NTE|18|L|
NTE|19|L|COMPARISON
NTE|20|L|
NTE|21|L|MRI lumbar spine exams October 3, 2013 and December 2, 2011.
NTE|22|L|
NTE|23|L|CONTRAST
NTE|24|L|
NTE|25|L|15 cc intravenous Magnevist.
NTE|26|L|TECHNIQUE
NTE|27|L|
NTE|28|L|Sagittal T1, T2 FSE and T2 FSE with fat saturation as well as axial T1 and T2 FSE
NTE|29|L|images were acquired. In addition, axial and sagittal T1 post contrast images
NTE|30|L|were performed with fat saturation.
NTE|31|L|FINDINGS
NTE|32|L|
NTE|33|L|Extensive white laminectomies from L2-L5 enhancing granulation tissue is noted
NTE|34|L|within the operative bed. There is significant inflammatory enhancement involving
NTE|35|L|the left L4-5 facet with extension into the left neural foramen and left lateral
NTE|36|L|and anterior epidural space. Significant enlargement/hypertrophy of the left L4-5
NTE|37|L|facet. Enhancement encases the left L4 nerve root and the left L5 nerve root. No
NTE|38|L|localized rim-enhancing fluid collection. Previously noted left iliopsoas and
NTE|39|L|paraspinous muscular rim-enhancing collections are no longer present
NTE|40|L|
NTE|41|L|Small residual central/left central protrusion measuring approximately 3 mm in
NTE|42|L|diameter. Asymmetric left facet arthropathy. These findings contribute to
NTE|43|L|asymmetric left subarticular recess narrowing and displacement of the left
NTE|44|L|traversing L5 nerve root. There is mild right foraminal narrowing.
NTE|45|L|
NTE|46|L|At L2-3 there is a left foraminal annular fissure and protrusion measuring
NTE|47|L|approximately 3-4 mm in diameter causing mild displacement of the left L2 nerve
NTE|48|L|root in the neural foramen. Central canal and right neural foramen are patent.
NTE|49|L|At L3-4, there is subtle grade 1 retrolisthesis with broad disc bulging measuring
NTE|50|L|approximately 3 mm in diameter. There is mild endplate osteophyte formation and
NTE|51|L|mild foraminal narrowing. Central canal is decompressed.
NTE|52|L|
NTE|53|L|At L5-S1, there is a right central/subarticular annular fissure and a central to
NTE|54|L|right subarticular shallow protrusion measuring approximately 3 mm in diameter.
NTE|55|L|No S1 nerve root displacement. Mild right greater left foraminal narrowing.
NTE|56|L|
NTE|57|L|Conus medullaris is normal in size and configuration terminating at the L1
NTE|58|L|vertebral body level. Stable left renal cystic change.
NTE|59|L|
NTE|60|L|ELECTRONICALLY SIGNED BY: Doctor M.D., John on May 20, 2014
NTE|61|L|
NTE|62|L|---------------------------------------------------------------------------
NTE|63|L|Electronically Signed By: Doctor M.D., John
