MRI Transcription Sample Reports For Medical Transcriptionists

MRI SCAN OF THE BRAIN WITH AND WITHOUT CONTRAST:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  Focal speech deficits.

Multiplanar sagittal, axial and coronal images were obtained through the brain prior to and following contrast administration.  Inversion recovery images identify two focal areas of abnormal increased signal involving the left temporal lobe as well as the right occipital lobe.  This shows abnormal signal, particularly involving the gyri.  Following contrast administration, there is some evidence of enhancement to these areas without clear indication of any specific focal mass or mass effect.  I believe these findings represent ischemic foci.  Enhancement pattern is typical of what is known as luxury perfusion.  Again, no mass effect noted.  No clear indication to suggest any abnormal intracranial mass or abnormal vascularity such as an arteriovenous malformation.

IMPRESSION:  Two focal areas of abnormal signal change.  One appears in the left temporal lobe with specific focal gyral enhancement.  Additional focus appears within the right occipital lobe region, again within the periphery with characteristic gyral enhancement.  These findings would be consistent with an ischemic focus.  Enhancement is typical of luxury perfusion, often seen in subacute infarcts.  The remainder of the intracranial examination is unremarkable.

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MRI SCAN OF THE LEFT SHOULDER:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  Chronic pain and limited range of motion.

Multiplanar axial, sagittal oblique and coronal images were obtained through the left shoulder.  Osseous structures themselves are unremarkable without bone contusion or occult-type fracture.  Acromioclavicular joint appears intact.  No indication of any significant inferior spurring to result in an impingement.  The images through the rotator cuff show complete tear with retraction of the supraspinatus tendon component.  In the void, notice made of some effusion as might be anticipated.  The images through the glenoid labrum show intact superior and inferior lips.  The anterior and posterior lips of the glenoid labrum also appear intact.  No indication of any subluxation of the biceps tendon.

IMPRESSION:  Complete tear of the rotator cuff with retraction of the supraspinatus muscle and tendon component.   Slight high-riding position of the humeral head as might be anticipated.  Acromioclavicular joint does not show any significant inferior spurring to result in an impingement.  Intact glenoid labrum.

MRI Sample Reports      

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MRI SCAN OF THE LUMBAR SPINE:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  Lifting injury.

Multiplanar sagittal and axial images were obtained through the lumbar spine.

L5-S1:  There is evidence of a large central-to-right side disc protrusion at this level, which results in displacement and compromise of the subarticular portion of the right S1 root.  Left S1 root does not appear affected.

L4-L5:  Significant disc space narrowing with central disc herniation of moderate size.  This results in partial effacement of the ventral portion of the thecal sac.  No clear indication of any compromise of either exiting root however.

L3-L4:  This by far is the most affected level with disc space narrowing.  Both the sagittal and axial images indicate large disc protrusion centrally and slightly to the right side.  I believe this serves to compromise the thecal sac significantly.  Herniated disc material, which still appears contiguous with the disc space occupies the majority of the thecal sac showing significant effacement.

L2-L3:  Normal cross-sectional appearance without epidural compromise of the canal or roots.

IMPRESSION:  Multilevel degenerative changes.  Most affected level appears at L3-L4 with large central-to-right side disc protrusion remaining contiguous with the disc space.  Disc material occupies the majority of the remaining thecal sac, which shows significant effacement.  L4-L5 shows moderate central disc herniation without either left or right side predominance.  Thecal sac appears compromised as a result.  L5-S1 shows large central-to-right side disc herniation resulting in compromise of the subarticular portion of the right S1 root.


MRI SCAN OF THE PELVIS:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  Reported fullness, status post hysterectomy and right side oophorectomy.

There are no prior films available for review.  Neither ultrasound nor CT examination have been submitted.  Images through the pelvis were obtained utilizing axial, sagittal and coronal projections.  Pre- and post-contrast images were also obtained.  Sagittal images show normal appearance of the fluid-filled bladder.  There is a linear-type low signal structure interspersed between what appears to be the rectum and bladder.  This appears to be a continuation of the vaginal cuff and perhaps represents scar tissue.  This does not show any specific enhancement.  I do not believe this represents any bowel.  The remainder of the pelvis is otherwise unremarkable without findings of any free fluid or unusual adnexal masses.  The osseous structures are unremarkable to include the iliac bones in both hips.

IMPRESSION:  Linear shelf-like low attenuation signal interspersed between the fluid-filled cystic bladder and rectum.  I am unclear as to the exact significance of this finding.  This may well represent a component of fibrosis or scar.  This does not show any enhancement with contrast.  I do not believe this represents any bowel loop.  My recommendation for further evaluation would be CT scan of the pelvis with intravenous contrast to opacify the bladder and also rectal contrast to delineate the boundaries of the rectum.  No clear indication of any contained mass or obvious free fluid.

MRI Sample Reports 1      

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MRI SCAN OF THE HEAD WITH AND WITHOUT CONTRAST:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  History of abnormal CT scan.  A patient with reported closed head injury and psychotic episodes.

The CT examination is not available for review.  Multiplanar sagittal, axial and coronal images were obtained to the brain prior to and following contrast administration.  The ventricles and sulci do show slight prominence indicating mild cortical atrophic changes, somewhat advanced for this patient.  No findings of any specific asymmetry however.  No indication of any encephalomalacia to suggest prior infarct or other type injury.  Post-contrast images failed to identify any abnormal enhancement.

IMPRESSION:  Mild atrophic changes, advanced.  No indication of any specific encephalomalacia changes to suggest prior infarct or ischemic event.  No midline shift.  No findings of any specific mass.  No abnormal intracranial enhancement.

MRI Sample Reports 2     

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MRA INTRACRANIAL CIRCULATION:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  Focal speech deficits.

Multiple time-of-flight images were obtained through the intracranial circulation supplemented by the axial source images.  Images through the circle of Willis do not highlight any specific anomaly or aneurysmal dilatation at any of the branch points.  Overall appearance of the vessels between the left and right sides are normal and symmetric.  I did not identify any specific truncation of the terminal branches of the anterior or posterior circulation.  Detail of the carotid siphons is somewhat limited due to the patient’s body habitus.

IMPRESSION:  No indication of any truncation of the terminal branches of either of the anterior or posterior circulation.  No aneurysmal dilatation at any of the branch points.  Normal and symmetric flow through each carotid siphon.  Flow established as well in the basilar artery.


MRI SCAN OF THE THORACIC SPINE WITH AND WITHOUT CONTRAST:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  Thoracic laminectomy.

Sagittal images indicate multilevel changes primarily affecting the T9-T10, T8-T9, T7-8 and T6-T7 levels.  Review of the earlier examination has been made.  The addition of the contrast highlights postoperative changes involving the posterior elements through these levels.  Detail is more exquisite with the addition of contrast.

T9-T10:  There remains a large central-to-right side disc herniation serving to efface the thecal sac.  I would estimate this to represent a severe stenosis as a result of the epidural compromise from the remaining disc.  These findings, I believe, are also confirmed on the sagittal images.

T8-T9:  Similar findings with epidural compromise as a result of the large disc protrusion, central and to the left.  As a result, the remaining thecal sac appears effaced and displaced to the right side.

T7-T8:  Findings again demonstrate disc protrusion, central and to the left side.  Cord does not show any significant effacement or displacement at this level.

T6-T7:  Large disc protrusion, central and to the right.  As a result, the cord shows slight displacement to the left side.  No significant effacement of the cord however.

IMPRESSION:  Current examination is better detailed than when compared to the previous study.  I believe the postcontrast images offer the best detail of the thoracic canal and ultimately the cord.  Significant epidural compromise of the thecal sac and ultimately the cord at the levels of T9-T10, T8-T9, T7-T8 and T6-T7.  Most affected levels appear at T9-T10 with large central-to-right side disc component serving to significantly efface the thecal sac and ultimately the cord at this level.  Large disc protrusion at T8-T9 displacing the remaining thecal sac and cord to the right side.  Disc protrusions at T7-T8 and T6-T7, however, not as severe as the other two levels.  Postoperative changes as discussed.  It is difficult to compare these studies with the previous films.  The postcontrast T1 weighted images are much improved when compared to the earlier study offering better detail.

MRI Sample Reports 3      

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MRI SCAN OF THE CERVICAL SPINE:

DATE OF STUDY:  MM/DD/YYYY

CLINICAL HISTORY:  Degenerative changes.

Multiple contiguous axial and sagittal images were obtained through the cervical spine prior to and following contrast administration.  Sagittal images indicate normal craniocervical junction level.  Cord does not exhibit any abnormal signal change.

C7-T1:  Prominent disc protrusion to the left side serving to severely compromise the C7-T1 level on the left.  Right side foramen shows patency.  There is partial effacement of the cord on the left side.  No abnormal cord signal change.

C6-C7:  Desiccation together with loss of disc height.  Prominent left side disc protrusion as well serving to severely compromise the left side C6-C7 foramen.  Partial effacement of the cord on the left side as a result.  I believe there is a component to the right side, which also severely compromises the right side C6-C7 foramen.  No abnormal cord signal change.

C5-C6:  There is evidence of a large central focal disc protrusion to the left side serving to significantly efface the left side of the cord.  No abnormal cord signal change.  The disc to the left severely compromises the C5-C6 foramen.  I believe, there is probable uncinate hypertrophy and perhaps a disc component serving to severely compromise the C5-C6 foramen.  No indication of any abnormal signal change within the cord or formation of a syrinx.

C4-C5:  Similar findings with left side disc herniation severely compromising the left side C4-C5 foramen.  Right side foramen shows relatively wide patency.  Partial effacement of the left side of the cord.

C3-C4:  Large central disc protrusion serving to ventrally efface the cord.  No abnormal cord signal change however.  I believe there is severe compromise of the left side C3-C4 foramen as a result of the soft tissue component.  Right side foramen shows patency.

C2-C3:  Normal cross-sectional appearance.

IMPRESSION:  Multilevel degenerative changes affecting primarily C6-C7, C5-C6 and C3-C4 most severely.  Cord appears most compromised at the C3-C4 level due to the central nature of the disc.  No abnormal cord signal change however.  C5-C6 shows more focal eccentric left side disc herniation serving to severely compromise the left side of the cord.  I do not identify any specific abnormal signal within the cord to suggest contusion or suggestion of a syrinx.


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