CT Left Shoulder Report Sample:

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PATIENT NAME:   Debra Jones
ID NUMBER: 240804
REFERRING PHYSICIAN: Dr.
DATE OF SERVICE:  12/01/10
DOB:  

NONCONTRAST CT OF THE LEFT SHOULDER:

CLINICAL HISTORY:  Left shoulder pain.

TECHNIQUE:  Standard noncontrast shoulder technique.

FINDINGS:  The obvious structures are intact. There is no dislocation. The infraspinatus and teres minor tendons are maintained. There is a focal vertical tear of the supraspinatus tendon at the insertion, which appears full thickness. There is no tendon retraction. The subscapularis tendon is intact.

The long head of the biceps tendon is in anatomic location and the biceps anchor is maintained. There is no detached labral tear.

The acromioclavicular joint is unremarkable. There is no glenohumeral joint effusion. There is no disproportionate muscle atrophy.

IMPRESSION:

1. Focal vertical/linear full-thickness tear of the supraspinatus tendon laterally at the insertion. No evidence for tendon retraction.