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MRI of Upper Arm Medical Transcription Example

DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATIONS FOR STUDY:  Abnormal soft tissue mass over right deltoid muscle.  Pain, paresthesia down arm.  Abnormal bone scan with no known primary.

TECHNIQUE AND FINDINGS:  Multiplanar images were obtained without and with contrast.  A vitamin E tablet was placed over the palpable abnormality.  The marker is along the lateral posterior humerus.  The patient shook throughout the exam.  The patient could not control the shaking.

Overall, the images are of diagnostic quality.  There is a fatty mass that follows fat on all sequences and does not enhance corresponding with the palpable abnormality.  This is compatible with a lipoma.  There is no soft tissue mass component.

Again, it appears to be homogeneous fat on all sequences suggestive of benign etiology.  This measures approximately 6.5 cm craniocaudal dimension x 3.3 cm AP dimension x approximately 2.5 cm transverse dimension.

The marrow signal within the humerus is homogeneous.  There is no abnormal low signal to suggest metastatic disease.  There is no frankly destructive lesion.

Muscle planes appear preserved.  There is no large fluid collection.

IMPRESSION:  The palpable abnormality corresponds with a fatty mass that does not enhance.  This is most suggestive of a lipoma.  Underlying bony structures appear intact without evidence of occult malignancy, as there is no abnormal low signal on T1 weighted sequences.