MRI Report Samples (7)

MRI Brain Report Sample #1

PATIENT NAME: David Jones
ID NUMBER: 123456
REFERRING PHYSICIAN: Harry Richard, M.D.
REFERRING PHYSICIAN’S FAX: 305-123-4567
DATE OF SERVICE: 01/01/11
D.O.B.:

MRI OF THE BRAIN WITH AND WITHOUT CONTRAST:

TECHNIQUE: MRI was performed of the brain prior to and following the administration of IV gadolinium utilizing standard protocol. No prior study is available for comparison.

CLINICAL INFORMATION: The basilar cisterns, ventricular system and cortical sulci appear unremarkable for a 67-year-old patient. The visualized mastoid air cells and paranasal sinuses appear clear. There are multiple small foci of increased signal on T2 weighted and FLAIR images in the subcortical white matter, predominately in the frontal regions of both hemispheres. There is no evidence of mass effect, midline shift, extra-axial fluid collection or hemorrhage. There are no abnormal areas of contrast enhancement identified within the brain.

The pituitary is not enlarged. The cerebellar tonsils are in normal anatomic position. The VII-VIII nerve complexes have a symmetric and unremarkable appearance without evidence of abnormal contrast enhancement.

IMPRESSION:

1. Focal abnormalities in the white matter as described above are generally associated with ischemic microvascular disease. A demyelinating process can have a similar appearance. Clinical correlation is suggested. See complete discussion above.




MRI Brain Report Sample #2

RE: Debra Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

MRI EXAMINATION OF THE BRAIN WITH AND WITHOUT CONTRAST:

REASON FOR EXAMINATION:

DISCUSSION: MRI examination of the brain is performed using the following protocol: T1 weighted sagittal and coronal, T2 weighted coronal, FLAIR and T1 weighted axial sequences. The patient refused contrast enhancement so post-contrast scans have not been done. Also, please note that diffusion scans have not been done. The brain parenchyma shows normal signal intensity on the various pulse sequences. There is no intracranial mass, mass effect or area of abnormal signal intensity. The right temporal horn is slightly prominent and asymmetric. Flow voids are appreciated in the major intracranial vessels.

IMPRESSION:

NORMAL NONCONTRAST MRI EXAMINATION OF THE BRAIN. PLEASE NOTE THAT DIFFUSION-WEIGHTED SCANS HAVE NOT BEEN DONE.




MRI Brain With & Without Contrast Report #3

RE: Debra Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

MRI EXAMINATION OF THE BRAIN WITH AND WITHOUT CONTRAST:

REASON FOR EXAMINATION:

DISCUSSION: MRI examination of the brain is performed using the following protocol: T1 weighted sagittal and coronal, T2 weighted coronal, FLAIR and T1 weighted axial sequences. The patient refused contrast enhancement so post-contrast scans have not been done. Also, please note that diffusion scans have not been done.

The brain parenchyma shows normal signal intensity on the various pulse sequences. There is no intracranial mass, mass effect or area of abnormal signal intensity. The right temporal horn is slightly prominent and asymmetric. Flow voids are appreciated in the major intracranial vessels.

IMPRESSION:

NORMAL NONCONTRAST MRI EXAMINATION OF THE BRAIN. PLEASE NOTE THAT DIFFUSION-WEIGHTED SCANS HAVE NOT BEEN DONE.




MRI Brain IAC Report #4

PATIENT NAME: David Jones
ID NUMBER: 123456
REFERRING PHYSICIAN: Harry Richard, M.D.
DATE OF SERVICE: 01/01/11
D.O.B.:

MRI OF THE BRAIN WITH IAC’S:

CLINICAL HISTORY:

TECHNIQUE: MRI of the brain was performed using a combination of T1 and T2 weighted axial, sagittal and coronal images. Additional thin section images were also obtained through the cerebellopontine angles for evaluation of the internal auditory canals.

CLINICAL INFORMATION: The brain parenchyma shows normal signal intensity. There is no confluent edema or mass effect. There is no extra-axial collection identified. The corpus callosum is well formed and it is in good position. The cerebellar tonsils are unremarkable. The pituitary gland is normal in size. The cavernous sinuses are symmetric. The basal cisterns are symmetric in appearance.

The cerebellopontine angle cisterns are normal in appearance, without mass or mass effect. The VII and VIII nerve complexes are unremarkable. There is no evidence for vestibular schwannoma or other mass. Trigeminal nerves are symmetric in caliber and in normal position. There are normal flow voids in the basilar artery and along the circle of Willis.

IMPRESSION:

1. The exam is within normal limits. The brain parenchyma is normal in appearance, without edema or mass identified. Cerebellopontine angle cisterns are intact, without evidence for vestibular schwannoma or other abnormality.




MRI Knee Report #5

RE: Debra Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

IMAGING SEQUENCES:Multiple pulsing sequences are performed at three planes with emphasis on T1, proton density, and T2 weighting.

FINDINGS: There are moderate intrameniscal myxoid changes in the medial meniscus. The intrameniscal myxoid changes are more pronounced in the posterior horn. There is no evidence of discrete meniscal tear extending to an articular surface in a linear fashion of either the medial or lateral meniscus. The anterior and posterior cruciate ligaments are intact. There is some edema medial to the MCL consistent with a grade I MCL sprain. There is also some fluid deep to the MCL below the joint line consistent with some TCL bursitis. There is a fairly large broad band of edema in the medial tibial plateau extending to the medial aspect of the lateral tibial plateau compatible with an area of edema, or contusion. There is some subchondral degenerative changes in the femoral condyle. A discrete fracture line is not identified. The lateral collateral ligament appears intact. The extensor mechanism appears intact. There is chondromalacia patella most pronounced along the lateral facet as well as the lateral aspect of the medial facet near the patellar apex. The chondromalacia patella is most pronounced at the level of the upper pole of the patella. A few small subchondral cysts are seen within the patella. There is a small joint effusion.

IMPRESSION:

GRADE I MCL SPRAIN.

TCL BURSITIS.

BAND OF EDEMA OR CONTUSION THROUGHOUT THE MEDIAL ASPECT OF THE PROXIMAL TIBIA AS NOTED ABOVE.

MEDIAL COMPARTMENT DEGENERATIVE CHANGES WITH INTRAMENISCAL MYXOID CHANGES WITHIN THE MEDIAL MENISCUS. NO EVIDENCE OF FRANC MENISCAL TEAR.

SMALL JOINT EFFUSION.

CHONDROMALACIA PATELLA.




MRI Lumbar Spine Report #6

RE: Debra Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

MRI EXAMINATION OF THE LUMBAR SPINE:

REASON FOR EXAMINATION: Low back pain, radiating to both thighs.

DISCUSSION: MRI examination of the lumbar spine is performed using the following protocol: T1 weighted and T2 weighted axial and sagittal sequences. The lumbar vertebral alignment is well maintained. The vertebral body heights and disc spaces are well maintained. Normal T2 hyperintensities are seen within all the discs in the lumbar spine. Axial scans are done from disc space level L2-L3 through L5-S1. At disc space levels L4-L5 and L5-S1, there are very minimal diffuse disc bulges. There is no focal disc herniation, canal stenosis or foraminal narrowing seen at any of the levels in the lumbar spine.

IMPRESSION:

VERY MINIMAL DIFFUSE DISC BULGES SEEN AT LEVELS L4-L5 AND L5-S1.

THERE IS NO DISC HERNIATION, CANAL STENOSIS OR FORAMINAL NARROWING SEEN AT ANY OF THE LEVELS IN THE LUMBAR SPINE.




MRI Right Shoulder Report #7

PATIENT NAME: David Jones DOB:
DATE OF STUDY: 01/01/11 FILE#:
REFERRING PHYSICIAN: Harry Richard, M.D.

NONCONTRAST MRI OF THE RIGHT SHOULDER:

CLINICAL INDICATION: Impingement.
TECHNIQUE: Use the standard noncontrast technique.

 


FINDINGS:
The infraspinatus and teres minor tendons are intact. There is mild tendinosis of the supraspinatus tendon without tear. The subscapularis tendon is intact. The long head of the biceps tendon is in anatomic location and the biceps anchor is maintained.

There is moderate degenerative arthrosis of the AC joint and slight thickening of the coracoacromial ligament. These may contribute to clinical impingement. There is no joint effusion or disproportionate muscle atrophy.


IMPRESSION:

1. Mild tendinosis of the supraspinatus tendon without tear.>

2. Moderate DJD of the AC joint with slight thickening or the coracoacromial ligament. These may contribute to clinical impingement.

Thank you for your referral,