MRI Reports Medical Transcription Examples


MRI OF THE LEFT HEEL/CALCANEUS WITHOUT CONTRAST

HISTORY:  Heel pain, 3 months.  Soft tissue mass, lateral ankle.

TECHNIQUE:  Multiplanar images of the left heel/calcaneus were obtained without contrast.  The bony structures and articulations are maintained.  The marrow signal within the bony structures is unremarkable.  There is no obvious fracture or dislocation.  The Achilles tendon does have some increased signal intensity within it on the T2 and T1 weighted sequences.  Additionally, there is some fluid along the medial anterior aspect of the Achilles tendon.  This combination of findings may represent partial tear to the Achilles tendon.  The marker is placed posterolaterally.  In this area, there is some focal fat.  Anterior to the marker, the peroneus longus and brevis tendons are located.  Overall, the peroneus tendons appear intact.  They may have minimal fluid adjacent to them that could represent tendinitis.  There is no abnormal increased signal within the peroneus tendons, however.  There is some fluid anterolateral to the flexor hallucis longus muscle/tendon.  This fluid appears to extend posterior to the talus and in the posterior talofibular joint space.  
The muscles and tendons are otherwise preserved.  No other large fluid collections identified.

IMPRESSION:
1.  Achilles tendon is notable for slight increased signal as well as fluid adjacent to Achilles tendon.  The combination of findings may represent a partial tear or tendinosis.
2.  The marker is placed posterolaterally in the area of fat.  It is lateral to the Achilles tendon and posterior to the peroneus longus and brevis tendons.  There is some slight fluid adjacent to the peroneus tendon that may represent some mild tendinosis or tenosynovitis.
3.  There is some fluid along the anterolateral aspect of flexor hallucis longus muscle and tendon that appears to extend posteriorly in the region of the talofibular joint.


MRI OF THE BRAIN WITHOUT AND WITH CONTRAST

HISTORY:  Numbness and head pain.

Multiplanar images of the brain were obtained without and with contrast.  There is right maxillary mucosal thickening with a narrow fluid level posteriorly, rather small but they represent some acute sinusitis.  The ventricles are symmetric.  There is no mass, mass effect or shift to midline structures.  With contrast, there is no abnormal enhancing lesion.  There is no extra-axial fluid collection.  There is no obvious infarct.

IMPRESSION:
There is right maxillary mucosal thickening with a small area of fluid level.  Some sinusitis on the right is not excluded.  The remainder of the brain without contrast and with contrast is unremarkable.


MRI OF THE RIGHT SHOULDER WITHOUT CONTRAST

HISTORY:  The patient had focal trauma to the upper arm.

We see a large, approximately 1 cm cystic structure at the superolateral humeral head near the attachment site, which is on the tendon.  Directly adjacent to that distal supraspinatus tendon, we do see abnormal signal of the tendon anteriorly and loss of clear tendon fiber definition near the attachment.  This could indicate a full-thickness tear of a few fibers of the supraspinatus tendon or a significant partial tear with tendinosis.  The remaining aspect of the supraspinatus tendon is intact without significant retraction.  The AC joint does show some moderate hypertrophy with both caudal and cephalad extension.  The caudal extension does appear to depress the underlying supraspinatus structure somewhat but does not cause significant edema to suggest a definite impairment radiographically.  We do see a tear of the distal subscapularis tendon in the mid section.  No full-thickness retraction is noted in this area.  It is most likely an intratendon tear.  It extends about 1.5 cm retrograde from the insertion site.  There is a question of some bruising and possible mild medial dislocation.  The subscapularis tendon is not completely torn; however, it corresponds to complete dislocation medially, but there is some edema around that area of the biceps tendon inferiorly as this is felt to cross across the humeral head.  Besides the cystic change in the superolateral humeral head, there is no other focal contusion or microfracture that is suggested of the humerus or the glenoid.  The glenoid labrum appears grossly intact on this exam.  There is moderate amount of joint effusion present, which is felt overlying that structure.  Infraspinatus and teres minor muscles are intact.  The deltoid muscle is intact without hematoma or tearing.  There is a fluid collection in the subscapularis recess.

IMPRESSION:
1.  There is a 1 cm cystic change noted at the superolateral humeral head near the anterior supraspinatus contusion site and some signal changes of the distal supraspinatus tendon near the anterior aspect of its course.  There is suggestion of a significant probable partial tear and tendinosis in this area.  No significant tendon retraction is noted of the supraspinatus structure.
2.  Moderate degenerative change of the AC joint with some mild inferior and superior inflammation within the joint.
3.  A moderately significant intrasubstance tear is suggestive of the subscapularis tendon.  No full-thickness tear or contracture is noted.
4.  Abnormal high signal of the more superior portion of the biceps tendon is also suggested and its pathway is not as clear once this crosses superiorly and if it is crossed across the humeral head.  A mild subluxation of this position could be present.


LEFT SHOULDER MRI:

Left shoulder MRI is performed in the usual fashion.  There are numerous areas of high signal involving the superolateral humeral head.  There is a small cortical disruption indicating a partial or nondisplaced complete fracture involving the superolateral component of the humeral head.  There is edema in this area.

The overlying supraspinatus tendon does not show evidence of significant edema.  No evidence of tearing or retraction.  The area of abnormality involves the bony structures itself.

The biceps tendon remains in the normal location.  A small amount of fluid is noted around it.  The subscapularis and remaining rotator cuff tendons are intact and in normal position.

The AC joint shows some moderate hypertrophy with both superior and caudal bony spur extension.  This does not appear to significantly impress the underlying supraspinatus structures but that would need to be correlated to the clinical examination.

IMPRESSION:  
1.  Partial or nondisplaced complete fracture of the superolateral humeral head is suggested with surrounding edema.  No involvement of the overlying rotator cuff tendons is present.  The biceps tendon remains intact.
2.  No bony contusion or irregularity of the glenoid bony structure is definitely seen.


MRI OF THE RIGHT UPPER ARM

On this exam, 5 views were taken using coronal and sagittal imaging.  The humerus is intact.  No fractures are noted.  No contusions of the bony structures or cortical breakage.  The musculature of the triceps, biceps and brachialis structures are all intact without evidence of seroma, muscle contusion or obvious muscle retraction.  No evidence of obvious tendon tears in this area is noted.

IMPRESSION:
MRI of the right humerus shows no evidence of bony deficits, contusion or breakage and no gross abnormalities to the muscular structures of the arm as well.


MRI OF THE ABDOMEN AND PELVIS WITHOUT AND WITH CONTRAST

Multiplanar images of the abdomen and pelvis were obtained without and with contrast.

MRI OF THE ABDOMEN

There is a large fluid collection in the left upper quadrant measuring 7.5 cm transverse x 7.2 cm craniocaudal x approximately 9.2 cm AP dimensions.  This appears to be fluid as it is low signal on T1 and high signal on T2.  It is superior to the left kidney, seen along the posterior aspect of the left kidney, inferior to the spleen.  This could represent postsurgical fluid collection.  Possibly, it could be a cyst; however, this is less likely given its appearance.  The right kidney has 2 cysts in the upper pole, one anterior and one lateral.  The left kidney has a less than 1 cm cyst anteriorly involving the upper pole.  The ureters appear normal in course and caliber.  No other focal lesions are identified involving the kidneys.  The adrenal glands appear grossly unremarkable.  With contrast, there are no abnormal enhancing lesions.

IMPRESSION:
1.  There is a large fluid collection in the left upper quadrant inferior to the spleen, superior to the kidney, posteriorly located, that is quite large.  This could be a postop seroma or evolving hemorrhagic collection.  It possibly could be a renal cyst.
2.  Bilateral renal cysts, 2 on the right and 1 on the left.
3.  There is no abnormal enhancing lesion.  No other lesions are identified.

MRI OF THE PELVIS

Multiplanar images of the pelvis were obtained.  The bladder has loose walls.  There is no obvious mass involving the bladder.  Bony structures are intact. Muscle bundles are preserved.  No other abnormal mass or fluid collections are identified.

IMPRESSION:
There is no abnormal enhancing lesion.  Bladder is unremarkable.  No masses identified.


MRI SCAN OF THE RIGHT HAND

CLINICAL HISTORY:  Acute injury.

Marker has been placed at the indicated complaint site, which is overlying the dorsum of the hand and wrist at the level of the base of the third metacarpal and underlying capitate.  Evaluation of the osseus structures showed intact metacarpal bones numbering 1 through 5 without findings of any specific occult-type fracture or obvious bone contusion.  Evaluation of the carpal bones, especially at the complaint site, shows normal appearance and contour of the capitate carpal bone.  Adjacent hamate as well as the hook of the hamate appear intact.  Pisiform and both the greater and lesser multangulars also appear intact.  Carpal navicular does not exhibit any specific abnormal signal change or fracture.  Lunate is in normal position and normal appearance.  Distal radius and ulna are also unremarkable.  The coronal and axial T2 weighted images show several focal collections of fluid, notably in the radial scaphoid space.  This may reflect some component of injury to the hyaline cartilage within this joint space, also small focal amount of fluid within the radioulnar space.  Evaluation of the triangular fibrocartilage in this region does not highlight any specific gross abnormality.  These are not dedicated images of the wrist however.  Also some amount of free fluid surrounding the pisiform bone.  No findings of any obvious dislocation.

IMPRESSION:
Marker indicates complaint overlying the region of the base of the third metacarpal and capitate.  No clear indication of any underlying bone contusion or occult-type fracture involving the metacarpal bones and their articulation with the distal row of carpal bones.  There are focal areas of fluid collection as mentioned above, which may indicate some component of injury to the hyaline cartilages or perhaps the intercarpal ligaments, not readily apparent.  There appears to be more fluid collection surrounding pisiform and appearing between the radioulnar space; however, the triangular fibrocartilage appears grossly intact.  The patient does not exhibit any specific pain over this region.


MRI OF THE RIGHT ANKLE

HISTORY:  History of ankle pain.

Routine imaging was performed in all 3 orthogonal planes.  We see a small area of degenerative disk of the inferior posterior tibial plafond.  This articulates to the tibiotalar joint.  There is also a focal deficit seen in the superior lateral tibial plateau indicating an area of contusion and proximal microfractures.  This suggest some mild high signal on T2 and low signal on T1 indicating some acute edema in the area.  The sagittal images do suggest on T1 weighted some demarcation lines indicating what may be a developing osteochondral defect involving the superolateral talar dome.  Dome and joint bodies in the tibial talar joint spaces are noted.  We do see also some irregular markings of the distal talus involving the anterior and dorsal aspect.  The demarcation lines are suggesting some probable microfractures and edema in this region.  This could be related to prior trauma and simply not completely healed.  With regards to soft tissues, we do see some small fluid between the lateral aspect of the talonavicular joint region and the extensor digitorum brevis muscle.  No significant tearing of the muscle is noted.  The fluid is apparent between these 2 structures and one image suggests a very small contusion of the navicular bones in that area.  We also see some fluid around the flexor hallucis longus tendon.  This is seen as it wraps around the tibia that extends anteriorly.  We see some thickening of the more anterior component, which may indicate that it has been injured in the past and has repaired itself.  There was no fluid within the tendon proper to indicate a partial tear tendinosis at the time, but there may be a small synovial inflammation as the fluid around the tendon is slightly greater than normally seen.  Again, no partial or complete acute tear is noted.  No tears of the peroneus tendons or posterior tibialis tendon were definitely seen on this exam.  Small amount of fluid is noted in the sinus tarsi.

IMPRESSION:
1.  There is a very small signal change noted at the superolateral talar dome, which presents as low on T1 and higher on T2 suggesting edema.  T1 does suggest well-demarcated lines that represent a small osteochondral defect; it may be forming in this region.  No loose joint bodies in the tibiotalar joint spaces noted.
2.  There are some small degenerative cysts noted of the posterior tibial plafond, may indicate degenerative or perhaps old changes to that region.
3.  There are some signal changes also of the distal anterior talus near the dorsal aspect of the talonavicular joint space.  This area of high signal suggests some contusion or microfracture.  No malalignment of a full fracture is present.
4.  There is fluid around the flexor hallucis longus tendon indicating what may be synovitis.  It is slightly greater than normally seen.  The tendon itself is slightly more thickened.  This artifact may represent some old partial tears and reparative changes.  No acute tendinosis or tearing is seen.
5.  The capsule indicated an area of discomfort noted by the extensor digitorum longus tendon and muscle and no significant abnormal signal or unusual masses are noted in that area.


MRI OF THE LEFT WRIST:

HISTORY:  Left wrist/forearm mass, one year, getting larger.

Multiplanar images were obtained without and with contrast.  The mass follows the fat on all sequences.  This does not enhance.  This is most suggestive of a lipoma.  This measures 3.6 cm craniocaudal dimension x 1 cm transverse x 1.6 cm AP dimension.  It does suppress on the fat suppression technique.  There is no soft tissue component.  This corresponds with the marker and is adjacent to the distal radial metadiaphyseal region along the radial aspect.

There is incidental note of some fluid distal to the radial styloid as well as distal to the ulnar styloid.  The marrow signal within the bony structures is unremarkable.

IMPRESSION:  The palpable abnormality corresponds with a simple lipoma as it does follow the signal intensity for fat on all sequences and does not enhance.  There is no soft tissue component.  This is located along the radial aspect of the distal radial metadiaphyseal region.  It does suppress on the fat suppression sequences as well.  No other focal lesion is identifiable aside from incidental note of some fluid distal to the radial styloid as well as the ulnar styloid.

MRI OF THE RIGHT SHOULDER:

Multiplanar images were obtained.  There is a full-thickness tear of the anterior component of the supraspinatus tendon with some minimal retraction.  There are degenerative changes involving the AC joint with inferior and superior osteophyte formation.  There is some high signal in the subscapularis tendon suggestive of possible injury with suggestion of some partial retraction.  The glenoid labrum appears grossly intact.  Marrow signal within the bony structures is within normal limits.  Biceps tendon is well located within the groove.

IMPRESSION:

1.  Degenerative changes involving the acromioclavicular joint.
2.  Full-thickness tear of anterior component of the supraspinatus muscle/tendon with some minimal retraction.
3.  There is suggestion of injury in the subscapularis tendon as there is some fluid in this area.  Some minimal retraction is not excluded


MRI OF THE HEAD:

HISTORY:  Severe headaches.

Routine MRI of the head reveals no suspicious mass or mass effect.  No midline shift.  No white matter areas of demyelination to indicate ischemic or demyelinating disease.  The brain stem is intact.  Craniocervical junction is normal.  No pathology within either of the globes of the eye are noted nor within the retrobulbar region.

We do see that there is some right circumferential maxillary sinus disease and left circumferential frontal disease.  In addition, there is some bilateral ethmoid disease of the sinuses.

IMPRESSION:  
1.  Incidental note of sinus disease with an area in the left frontal region also present.
2.  No evidence of white or gray matter demyelination, mass, or mass effect.


MRA OF CIRCLE OF WILLIS:

HISTORY:  Left arm numbness.  Left headache, since resolved.  Previous TIA.

A 3D time-of-flight study was performed.  Raw data and composite images are available for interpretation.  Carotid arteries are symmetric.  The middle cerebral arteries are fairly symmetric.  There is absence of the anterior communicating artery as well as incomplete visualization of the distal A1 and proximal A2 segments of the anterior cerebral artery.  This could be due to slow flow or stenosis.  The distal aspect of the anterior cerebral artery, A2 component, is visualized.  No aneurysms are identified.  No obvious stenoses are identified involving the posterior circulation.

IMPRESSION:  Incomplete visualization of the anterior communicating artery and distal A1 and proximal A2 segments of the left anterior cerebral artery. This could be due to slow flow or stenosis in this area.  Lack of the anterior communicating artery could be a normal variant.  No aneurysms are identified. No other abnormalities are identified.


MRI OF THE LEFT CALF:

HISTORY:  Left calf pain, burning.  Evaluated for tear of the gastroc muscle or plantaris.

Multiplanar images were obtained without contrast through the left lower extremity.  The marrow signal within the bony structures is unremarkable.  There is no fracture.  There is increased signal on the STIR sequences in the gastrocnemius muscle medially along the inferior aspect suggestive of a partial tear.  The remainder of the muscular bundle is unremarkable.  In particular, the plantaris muscle appears intact.  No large fluid collection is identified.

IMPRESSION:  Increased signal along the inferior aspect of the medial head of the gastrocnemius muscle suggestive of partial tear.  There is no retraction of the muscle.  No other focal abnormality is identified.


MRI OF THE BRAIN WITHOUT AND WITH CONTRAST:

HISTORY:  Headache with aura and visual loss.

Multiplanar images of the brain were obtained without and with contrast.  The craniocervical junction is within normal limits.  On the FLAIR sequences, there is a round area of high signal on the right adjacent to the frontal horn of the lateral ventricle measuring about 5 mm.  Superiorly is a low signal on T1 weighted images.  It was not enhanced with contrast.  This may represent a minimal area of small vessel/ischemic-type disease, possible MS, also minimal cystic/encephalomalacic-type change.  There is no mass effect or shift of midline structures.  There is no extra-axial fluid collection.  There is no acute infarct.

There is a 5 mm area of high signal on the T2 weighted sequences and minimally on the FLAIR sequences on the right along the anterolateral aspect of the clivus.  Could be some cystic change in the inferior aspect of the right sphenoid sinus/mucosal thickening.  Visualized sinuses are otherwise clear.  No abnormal enhancing lesion is identified.

IMPRESSION:
1.  A 5 mm area of high signal on the T2 weighted sequences on the right anterolateral to the clivus could represent some mucosal thickening in the inferior aspect of the right sphenoid sinus.
2.  The 4-5 mm area of high signal in the periventricular white matter on the right adjacent to the frontal horn of the lateral ventricle could represent small vessel/ischemic-type disease or possibly an MS plaque or other demyelinating-type process.  It is asymmetric with the left.  Does not appear to enhance with the contrast.  Possibly could be encephalomalacic change.  Some area of gliosis is also a consideration.  Followup MRI imaging may be of value.  With contrast, there is no abnormal enhancing lesion.  There is no mass effect or shift of midline structures.                                          

                              







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