MSH|^~\&|RAD|LVMH||SFMH|20160918200148|||||
PID|1|241027447PDI|||Test Patient^Elation^||19600427|M|||||||||||
ORC|NW|6688124|7588125|0|CM||^^M30^20140519130000^20140519133000||201405081107|||1234567890^Doctor^John^^MD|||||
OBR|1|6688124|7588125|72158^LUMBAR SPINE W/O \T\ W CONTRAST|12|201405081107|20140519130000|20140519133000||||||||||||7588125||201405202301|||F||
OBX|1|RP|72158^LUMBAR SPINE W/O \T\ W CONTRAST||See Comments||||||F|||201405202301
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|Axial images:
NTE|61|L|
NTE|62|L|L1-2: No disc protrusion. Facets are intact. No spinal stenosis or foraminal
NTE|63|L|narrowing.
NTE|64|L|
NTE|65|L|L2-3, L3-4, L4-5, L5-S1: See above.
NTE|66|L|IMPRESSION
NTE|67|L|Interval extensive wide laminectomy from L2-L5.
NTE|68|L|Inflammatory enhancement surrounding the hypertrophied left
NTE|69|L|L4-5 facet with enhancement extending to the left lateral recess and neural
NTE|70|L|foramen encasing the L5 and L4 nerve roots. Mild residual displacement of the
NTE|71|L|left traversing L5 nerve root.Resolution of abnormal
NTE|72|L|enhancement within the left iliopsoas and paraspinous musculature demonstrated on
NTE|73|L|the prior examination.
NTE|74|L|
NTE|75|L|ELECTRONICALLY SIGNED BY: Doctor M.D., John on May 20, 2014
NTE|76|L|
NTE|77|L|
NTE|78|L|---------------------------------------------------------------------------
NTE|79|L|Electronically Signed By: Doctor M.D., John
MSH|^~\&|RAD|LVMH||SFMH|20160918200148|||||
PID|1||A543950||Test Patient^Elation||19000122|F|||||||||||
ORC|NW|6688124|7588125|0|CM||||201405081107|||1234567890^Doctor^John^^MD|||||
OBR|1|6688124|7588125|TM_er^ED Physician Notes^^^Vomiting|12|201405081107|20140519130000|20140519133000||||||||||||||201405202301|||F||
OBX|1|TX|er^ED Physician Notes||See Comments||||||P
NTE|1||
NTE|2||
NTE|3|| * * * PRELIMINARY REPORT * * *
NTE|4||
NTE|5||Patient: Elation, Test Patient
FIN: 40436666
NTE|6||Age: 6 years Sex: F DOB: 01/22/1900
NTE|7||Associated Diagnoses: None
NTE|8||Author: Wagner, David MD
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. She also notes that she has some bright red blood in her stool over
the last 2 days, which she states is not unusual for her to have. Pt notes food
like emesis. Pt notes some fever (up to 101F on home thermometer), chills, and
fatigue as well. Pt denies dysuria, hematuria, back pain, edema, weakness,
headache, dizziness.. The onset was 1 days ago. The course/duration of
symptoms is fluctuating in intensity. The character of symptoms is food like
emesis. The degree at present is moderate. The exacerbating factor is eating.
The relieving factor is none. Risk factors consist of History of colitis. Long
term steroid use.. Associated symptoms: abdominal pain, diarrhea, fever, chills,
blood in stool, denies chest pain, denies shortness of breath, denies headache,
denies dizziness and denies back pain.
NTE|21||