MRI Transcription Sample Reports For Medical Transcriptionists:
MRI OF THE LEFT SHOULDER:
Left shoulder MRI is performed in the usual fashion. There is no evidence of a full-thickness rotator cuff tear. No high signal within the distal supraspinatus tendon of marked significance to indicate a significant tendinitis. There is only a very small amount of high signal directly at the insertion site of the distal supraspinatus tendon, which may indicate a very small amount of tendinosis directly at that insertion site area.
There is some moderate hypertrophy of the AC joint. There is inflammatory increase of fluid in the joint space itself. There is spurring both caudally and superiorly. The caudal spurring impresses upon the underlying supraspinatus structures somewhat. This may be producing some type of mild entrapment symptoms. One may want to correlate clinically to that entity.
Also, the most distal component of the acromion suggests what may be a small loose joint body or spur, which minimally depresses the underlying structures as well. In neither of these two areas do I see significant edema or irritation of the underlying supraspinatus structures radiographically.
The remaining rotator cuff tendons are intact. The glenoid and humeral bony structures do not show lytic or blastic disease or microfractures.
There is a focal area of high signal involving the inferior and anterior glenoid labral area. One may want to perform a CT arthrogram to rule out labral injury.
1. No full-thickness rotator cuff tendon tear or muscle or tendon retraction. Minimal high signal at the distal supraspinatus tendon insertion site to indicate possible mild tendinosis.
2. Acromioclavicular degenerative joint disease with cephalad and caudal spurring. The caudal spurring does impress upon the underlying supraspinatus structures minimally. Also, there is possible loose joint body near the inferior and lateral acromion, which may be depressing the underlying structures somewhat.
3. Questionable injury to the inferior, anterior glenoid labrum. Focal area of high signal is noted in that area. One may need to do an arthroscopic examination or perhaps a CT arthrogram to rule out labral injury.
MRI OF THE LEFT KNEE:
Left knee MRI is performed in the usual fashion. The patient had significant trauma. There is a nondisplaced fracture, which is vertical in orientation primarily between the condyles of the distal femur. Much edema is noted around it. The axial planes show a well-demarcated line extending directly between the medial and lateral femoral condyles and extending anterior to a location directly behind the patella. However, there is not a definite cortical break to the most anterior component to indicate that this is a complete fracture. No fragmentation is noted. Edema on either side of the fracture line is apparent. There is no meniscus in portions of the medial meniscus. This is either iatrogenic or is due to a complete tear and possible buckling. There is loss of the normal condyle surface involving the medial tibial plateau and medial femoral condyle.
The lateral meniscus anteriorly is intact. Posterior component suggests some mucoid degeneration and possible partial and peripheral horizontal tear.
The PCL is thickened and on fat saturated images shows some edema within it, which may indicate a strain. It is grossly intact. The ACL is not completely visualized on this examination and suggests that it is completely torn. Age of that tear is uncertain.
There is some chondral injury to the posterior patella and the anterior femoral condyle.
No Baker's cyst is present on this examination. Minimal joint effusion is present.
1. Nondisplaced fracture placed directly central between the lateral and medial femoral condyles extending both in anteroposterior and vertical component. Edema and contusion is noted around it. It is questionable as to whether it is complete. No dislocation or fragmentation is associated with it.
2. Either iatrogenic removal of part of the lateral meniscus or a complete tear with possible flap has occurred over time. There is chondral erosion noted at the lateral femoral condyle and lateral tibial plateau as well.
3. Posterior cruciate ligament appears grossly intact but does have edema and some thickening indicating a possible strain.
4. Anterior cruciate ligament is not visualized indicating that it is not intact. Age is uncertain however, as there is not much edema in that area to indicate an acute injury directly at that time.
MRA OF CAROTID ARTERIES:
A 3D time-of-flight study was performed. Contrast was not given, as venous access could not be obtained, despite attempts three times. Raw data was obtained as well as selected images of the right and left carotid artery separately as well as together. Vertebral arteries are also included on the composite images. The vertebral bodies appear fairly symmetric without significant, obvious narrowing.
The left internal carotid artery appears normal. There is no obvious stenosis involving the left system.
On the right, the internal carotid artery is narrowed compared with that of the left. This is not severe. This is moderate in significance. There is no obvious ulceration. The narrowing is in the region of the right carotid bulb and does appear to be moderate, approximately 50-70%, as appreciated by a carotid Doppler ultrasound.
1. The vertebral arteries appear symmetric and unremarkable.
2. The left system appears unremarkable. There is no obvious stenosis or ulceration involving the left internal or external carotid arteries.
3. On the right, there is some narrowing of the right internal carotid artery at the level of the bulb that appears moderate in degree. This is notably different than the left side. This stenosis is approximately 50-70% correlating with the findings by ultrasound. There is no obvious ulcerative plaque.
MRI OF THE LEFT HIP:
Multiplanar images were obtained without contrast. The left hip is markedly abnormal compared with that of the right. There is abnormal low signal involving the left femoral head, neck, and intertrochanteric region on T1 that is high signal on the STIR sequences. This is suggestive of edema in the proximal left femur. There is also some mild edema in the superolateral left acetabulum. There is a prominent left medial joint effusion involving the left hip. There is marked flattening of the superolateral left femoral head. The left hip appears slightly subluxed laterally, as there is a large medial joint effusion. The acetabulum still appears to cover the femoral head. This may be due to stage IV AVN, which appears as advanced articular collapse and osteoarthritis. There is a subtle lucent line through the femoral head on the left that could be a component of AVN. It possibly could represent a fracture; however, it is more difficult to see on the T1 weighted images and better seen on the STIR sequences. It is suggested on the axial images as well. If clinically warranted, a CT may be of value to ensure there is not an incomplete fracture. On the sagittal images, this linear component is less so appreciated as well.
The right hip is fairly normal in appearance. The femoral head on the right is well preserved. There is no flattening of the right femoral head. The right acetabulum is unremarkable. There is no obvious fracture or dislocation on the right. There is no significant joint effusion on the right.
IMPRESSION: Left hip is markedly abnormal compared with that of the right with edema, flattening, and collapse of the superolateral left femoral head. There is a line traversing the subchondral surface of the femoral head that may be a component of avascular necrosis. Alternatively, this may be related to the closed physis or perhaps an incomplete fracture. Most likely, this probably represents the closed physis. CT may be of value to ensure that there is not an incomplete fracture in this area. The left femoral neck is deformed and misshapened and widened compared with that of the right. This may be due to a long-standing process from a congenital anomaly. Sequela from perhaps hip dysplasia/dislocation is a possibility as well given the marked asymmetry in the two hips. There is a prominent medial left joint effusion. The right hip is unremarkable.
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