Help! Medical Record

  1. Medical Record

    MRI Study: Lumbar spine.

    Clinical Information: Low back pain. Right leg pain.

    Technique: 2 MR series (sagittal T2, axial Tl)

    Findings: No abnormal retroperitoneal or paraspinous soft-tissue masses are seen. The size and position

    of the conus medullaris appear normal.

    L2-3: There is concentric annular disk bulge and accompanying marginal osteophyte. There is mild

    ventral flattening of the thecal sac. There is mild to moderate degree of acquired spinal

    stenosis. Facet arthropathy contributes to this.

    L3-4: There is concentric annular disk bulge. There is mild ventral flattening of the thecal sac.

    L4-5: There is intervertebral disk degeneration and concentric annular disk bulge. There is mild

    ventral flattening of the thecal sac.

    L5-S 1: There is intervertebral disk degeneration.

    Impression: Mild to moderate central canal spinal stenosis at L2-3.

    Interpretation of Medical Record

    Abstract information from the medical record to complete the following questions.

    1.Why was this patient referred to x-ray?

    2. The L2-3 vertebral view showed the thecal sac flattened on what side of the spine?

    3. Intervertebral disk degeneration was demonstrated at what levels?

    4. At levels L3-5, the bulge is in a concentric annular shape. What does this mean?

    5. Where is the conus medullaris located?

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    About Beablessing

    Joined: Feb '04; Posts: 2


  3. by   2ndCareerRN
    If I had these types of questions, I would talk to the practitioner that ordered the studies, or talk to my current doc.

    Often the answer to one question will provoke another question, so sitting down to talk with the doc is probably the best way to go.


    Or maybe a google search on the terms you are looking for would turn up information like this:

    Dorsal means back, ventral means front. As the body is symmetrical, the same thing happens on both the left and right side of the body. This happens in each vertebra of the spine.

    Good luck