BONE FILM DICTATION TEMPLATES

 

Lumbar Spine Plain Film (Outpatient):

 

History: 

Low Back Pain

Technique:

[ ] views of the lumbar spine

 

Reference Study:

[ ]

 

Findings:

 

Segmental Numbering:  For the purposes of this study, the first well formed vertebral body at the lower aspect of the images is denoted L5.  (Note that transitional lumbosacral anatomy is present on up to 30% of patients.)

 

Lumbar Vertebrae:

Negative for fracture.

Negative for height loss / compression deformity.

No focal lesions seen. (note that plain film can be insensitive for this type of abnormality).

Disc Volumes:
Maintained at all levels.

 

Alignment:

Coronal and Sagittal aligment are maintained.

 

Pedicles, Transverse, and Spinous processes:

No abnormalities.

 

Degenerative Changes:

None significant.

 

SI Joint:

Unremarkable.

Other:

N/A

Impression:

No fracture. 

No significant degenerative changes.

 

*Consider MR for evaluation of the spinal canal, cord, and neural canals*

 

Knee Plain Film (Outpatient):

 

History: 

Pain

Technique:

[ ] views of the [ ] knee

 

Reference Study:

[ ]

 

Findings:

 

Bone: 

No fracture
No focal lesions

 

Cartilage:

Medial Compartment:  Maintained
Lateral Compartment:  Maintained

Patello-femoral Compartment:  Maintained

Osteophytosis:

None significant.

Aligment:

Normal

 

Intraarticular:

No effusion
No suspicous intraarticular body

 

Soft Tissues:

Unremarkable.

Other:

N/A

Impression:

No fracture. No significant degenerative changes.

 

*Consider MR for evaluation of the menisci, cartilage, and/or cruciate ligaments*