Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

MRI Medical Transcription Dictation Sample Report

LUMBAR SPINE MRI WITHOUT CONTRAST

CLINICAL HISTORY: History of back pain. No history of prior surgery.


TECHNIQUE AND FINDINGS: Multiplanar sagittal and axial images were obtained through the lumbar spine without contrast administration. Sagittal images indicate what appears to be congenital, blocked fusion involving the L1-L2 and L3-L4 levels. Cord terminates appropriately at the L1 level.


L5-S1: Desiccation and some disc space narrowing. Cross-sectional images indicate severe stenosis due to the facet arthropathy, ligamentum flavum hypertrophy and diffuse disc bulge. Small triangular configuration of the remaining thecal sac again indicating significant stenosis.


L4-L5: Significant disc space narrowing and endplate changes. This is no doubt compounded by what appears to be the congenital fusion, in which the adjacent endplates show advanced degenerative changes. Cross-sectional images again show significant severe stenosis in part due to the diffuse disc bulge, flavum hypertrophy and facet arthropathy. Very small residual remaining thecal sac noted.


L3-L4: No indication of any significant stenosis. Again, this level is probably congenitally fused.


L2-L3: Significant disc space narrowing with moderate diffuse disc bulge. Some flavum hypertrophy and facet arthropathy. This gives rise to a moderate stenosis.


L1-L2: Again, congenital fusion most likely. No significant stenosis at this level.


IMPRESSION: Probable congenital fusion with blocked vertebrae involving L1-L2 and L3-L4. As a result, the adjacent disc spaces show advanced degenerative changes. L5-S1 shows severe stenosis as a result of the combination of epidural diffuse disc bulge, facet arthropathy and flavum hypertrophy. Severe stenosis involving L4-L5 as well. Moderate stenosis involving L2-L3.


THORACIC SPINE MRI:


The thoracic spine shows the vertebral bodies to be grossly intact.  They are of normal height and contour.  There is no lytic or blastic disease or evidence of partial or complete fracture or contusion seen.  The sagittal images show the pedicles to be intact as well.

There is no evidence of significant focal disc disease.  No evidence of a disc herniation or large extra-axial mass, which is compressing the cord on this exam.

Some axial images were taken from T6 through T9 and do not show focal disc or neural foraminal disease.

The cord is intact throughout the thoracic spine.

IMPRESSION:  No bone contusion or fractures noted.  No cord or neural foraminal compromise is seen.  No significant focal disc disease is noted.

MRI OF THE RIGHT KNEE:

HISTORY:  Possible meniscal tear.  Lateral pain.

Multiplanar images were obtained.  The ACL and PCL are both intact.  The collateral ligaments are intact.  The marrow signal within the bony structures is unremarkable.  There is some suprapatellar joint fluid, more lateral than medial.  There is some fluid anterior and lateral to the ACL and minimally posteriorly to the PCL.  The menisci are intact.  There is some globular increased signal in the posterior horn of the medial meniscus suggestive of degenerative type change.  There is no discrete linear area of signal that touches upon the articular surface to suggest an acute tear.

IMPRESSION:
1.  Collateral ligaments, cruciate ligaments, the menisci are all intact.
2.  There is a suprapatellar joint effusion as well as some fluid anterior and lateral to the anterior cruciate ligament as well as posterior to the posterior cruciate ligament.
3.  No other focal abnormality is appreciated.

MRI OF THE BRAIN WITHOUT CONTRAST:

HISTORY:  Right neck and right parietal pain.  Recent episode of amnesia.

Routine images of the brain show, on the FLAIR images, small foci of high signal indicating some probable white matter demyelination just lateral to the mid section of the right lateral ventricle, in the area of the anterior parietal region.  T2 weighted imaging show no significant edema in this area.  No effacement of any of the sulci.  There is no mass effect or midline shift.  These three to four small white matter areas of change may represent demyelination from ischemic insult.  There is one or two very small, approximately 2 mm areas of abnormal high signal just lateral to the left anterior lateral ventricle region in the posterior frontal lobe area.

There is no evidence of a mass or mass effect on this examination.  No abnormal extra-axial fluid collections are seen.

The brain stem is intact.  Craniocervical junction is within normal limits.

IMPRESSION:  
1.  Several small white matter lesions are seen involving the right anterior parietal region just lateral to the lateral ventricle and two small white matter lesions just lateral to the left anterior lateral ventricle.  These reside in the posterior frontal lobe area.  There is no significant edema around any of these at this time.  No effacement of the sulci is present.  These are mostly likely the sequela of vascular insult.
2.  No other significant findings are present.