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Abdominal MRI Medical Transcription Sample Report

ABDOMINAL MRI WITH AND WITHOUT CONTRAST

DATE OF STUDY: MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Stage III adenocarcinoma of the endometrium, rule out lymphatic spread.

TECHNIQUE AND FINDINGS: MRI of the upper abdomen with and without gadolinium and T2 fat-saturated imaging shows no evidence of fatty masses.  No metastasis or nodular presence on the periphery of the liver is present to indicate malignant spread.

The spleen is unremarkable.  The kidneys show no abnormal enhancement but do show some cortical uniform enhancement, as one would expect.

We do see that there is a small 5 mm probable cyst in the inferior pole of the left kidney.  The spleen is unremarkable.  No significant paracaval or periaortic lymphadenopathy is definitely identified on this examination.

The bony structures of the thoracolumbar spine are unremarkable and show no enhancing abnormalities.

IMPRESSION:  No evidence of metastasis or lymphadenopathy in the upper abdomen.  Particularly, the liver shows no pathology.  The left inferior pole does suggest a 5 mm simple cyst.

MRI OF THE ABDOMEN AND PELVIS WITHOUT AND WITH CONTRAST

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

INDICATION FOR STUDY:  Leiomyosarcoma.  Hysterectomy (XX)years ago.

TECHNIQUE AND FINDINGS:  Multiplanar images were obtained without and with contrast of the entire abdomen and pelvis.  The patient was very claustrophobic.

The upper abdomen is unremarkable.  There is no obvious mass.  Intra-abdominal organs are grossly unremarkable.

In the pelvis, there is an ovoid mass posterior to the bladder along the left posterior aspect.  This is low signal on T1 and remains fairly low signal on T2, as it is not as bright as the bladder.  Therefore, it is not a cyst.  It does appear to enhance with contrast.  This may well represent recurrence of her primary leiomyosarcoma. The mass measures approximately AP dimension 2.3 x transverse dimension 3.0 x craniocaudal dimension 2.7 cm.

IMPRESSION:  There is a small mass posterior to the bladder, slightly to the left of midline, measuring about 3 cm that appears to be separate from the bladder.  This is low signal on T1, slightly higher signal on T2 but not nearly as high as the fluid within the bladder.  It does appear to enhance.  This is suggestive of a tumor.  It may well represent recurrence of a primary/previous leiomyosarcoma.  No other abnormality is identified in the abdomen or pelvis.  There is some motion artifact involving the abdomen images that may be due to respiratory artifact.

MRI OF THE ABDOMEN AND PELVIS WITHOUT AND WITH CONTRAST

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  Left lower quadrant pain, worse with bowel movement.

TECHNIQUE AND FINDINGS: Multiplanar images were obtained without and with contrast.  The liver, spleen, kidneys, gallbladder, pancreas, and adrenals appear grossly unremarkable.  Loops of bowel appear unremarkable.  There is no obvious mass, adenopathy, or abnormal fluid collection.  The bladder has smooth walls without obvious mass.  With contrast, there is no abnormal enhancing lesion.

IMPRESSION:  Unremarkable MRI of the abdomen and pelvis without and with contrast.  Correlation with a CT may be of value, as CT has better resolution than MRI for subtle abnormality.  There is no obvious mass, adenopathy, or abnormal fluid collection.  There is no abnormal enhancing lesion.

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