MRI Medical Transcription Sample Reports for Medical Transcriptionists

MRI SCAN OF THE RIGHT THUMB WITHOUT CONTRAST

DATE OF MRI: MM/DD/YYYY

CLINICAL HISTORY: Acute injury.

TECHNIQUE AND FINDINGS: Multiplanar axial, sagittal and coronal images were obtained through the right thumb without contrast administration. The sagittal images indicate a small avulsion-type fracture fragment emanating from the dorsal aspect of the base of the proximal phalanx. This is probably as a result of direct tension by the extensor pollicis longus tendon, which can be seen directly inserting upon this fracture fragment. Volar side flexor pollicis longus tendon remains intact. The coronal images through the base of the thumb do show intact collateral ligaments, both medial and lateral. There is a small joint effusion seen in the metacarpophalangeal joint as might be anticipated. The remainder of the osseous structures does not show any additional fracture or bone contusion.

IMPRESSION: I believe there is a small avulsion-type fracture fragment emanating from the dorsal aspect of the base of the proximal phalanx upon which the extensor pollicis longus tendon inserts. Intact flexor pollicis longus tendon. Collateral ligaments also appear intact. Small joint effusion as might be anticipated.

MRI Medical Transcription Sample Report #2

MRI SCAN OF THE LEFT FOREARM WITH AND WITHOUT CONTRAST

DATE OF MRI: MM/DD/YYYY

CLINICAL HISTORY: History of repeated trauma to the distal left forearm.

TECHNIQUE AND FINDINGS: Multiplanar sagittal, coronal and axial images were obtained through the left forearm prior to and following contrast administration. Markers have been placed near the patient’s indicated site of swelling, which includes the dorsum of the distal left forearm and also over the wrist.

Images through the osseous structures failed to identify any specific bone contusion or occult-type fracture. There is a small amount of effusion within the articulation between the distal radius and ulna and proximal row of the carpal bones. Images overlying the dorsum of the wrist, just underlying one of the markers, indicates small amount of fluid surrounding a couple of the superficial extensor group tendons to the digits. More proximally, over the dorsum of the left forearm, again notice was made of a small amount of fluid surrounding the extensor carpi brevis and longus tendons. The muscles themselves do not show any abnormal signal change to suggest either contusion, tear or hematoma. Contrast images failed to identify any specific abnormal enhancement.

IMPRESSION: Small amount of fluid surrounding the tendons supplying the superficial extensor group to the digits as well as more proximally involving the extensor carpi brevis and longus tendons. This finding would be consistent with a synovitis. No indication of any specific granulation tissue. The muscle belly themselves do not show any findings of any tear, hematoma or contusion. Osseous structures are unremarkable without involvement. No bone contusion or destructive-type changes. Small amount of fluid regarding the articulation of the proximal row of the carpal bones and the distal radius and ulna

MRI Medical Transcription Sample Report #3

MRI OF THE HEAD:

HISTORY: Frequent falls.

TECHNIQUE AND FINDINGS: Routine MRI reveals some probable chronic disease within the midline and right sphenoid air cells. They are filled with high substance. A very small possible mucus retention cyst is suggested in the inferior right maxillary sinus.

Within the brain parenchyma, we do see mild and diffuse atrophy. There is a small, approximately 1 cm area of high signal seen at the left posterior frontal-parietal junction area. This is not presenting with significant mass effect. I would recommend either the patient returns for gadolinium studies now or that a six-month followup of this area be performed to see if it remains stable or remits over time, as one would expect with a small vessel infarct, and at that time, a gadolinium study can be performed if it is persistent.

There are at least two, if not three, very small areas of high signal at the gray-white matter junction of the right posterior parietal-temporal area. These most likely are sequelae of small vessel infarct.

There is no large mass or mass effect noted. No areas that present with extra-axial fluid collection indicative of a subdural or chronic fluid collection.

The cerebellar tonsil is somewhat low lying, but it is not below the craniocervical junction line to suggest a Chiari malformation. The brainstem is intact.

IMPRESSION:
1. There is an approximately 1 cm area of high signal at the left posterior frontal-parietal junction area of the cerebral hemisphere. This is of high signal on the FLAIR imaging and could represent a small vessel infarct, a focal area of demyelination from other causes or even a very small tumor, although that is felt less likely. No mass effect is associated with it. I would recommend a six-month followup of this area, and at that time, gadolinium also be used to make sure there is no focal enhancement.
2. Two very small areas, approximately 2-3 mm, at gray-white matter junction of the right cerebral hemisphere suggests probable small vessel infarct. These two can be reassessed at the followup time in six months.
3. Probable chronic midline and right sphenoid sinusitis.
4. No large masses or mass effect, nor abnormal extra-axial fluid collections are noted.

MRI Medical Transcription Sample Report #4

MRI SCAN OF THE PELVIS

DATE OF MRI:  MM/DD/YYYY

CLINICAL HISTORY: Reported fullness, status post hysterectomy and right side oophorectomy.

TECHNIQUE AND FINDINGS: There are no prior films available for review. Neither ultrasound nor CT examination have been submitted. Images through the pelvis were obtained utilizing axial, sagittal and coronal projections. Pre- and post-contrast images were also obtained. Sagittal images show normal appearance of the fluid-filled bladder. There is a linear-type low signal structure interspersed between what appears to be the rectum and bladder. This appears to be a continuation of the vaginal cuff and perhaps represents scar tissue. This does not show any specific enhancement. I do not believe this represents any bowel. The remainder of the pelvis is otherwise unremarkable without findings of any free fluid or unusual adnexal masses. The osseous structures are unremarkable to include the iliac bones in both hips.

IMPRESSION: Linear shelf-like low attenuation signal interspersed between the fluid-filled cystic bladder and rectum. I am unclear to the exact significance of this finding. This may well represent a component of fibrosis or scar. This does not show any enhancement with contrast. I do not believe this represents any bowel loop. My recommendation for further evaluation would be CT scan of the pelvis with intravenous contrast to opacify the bladder and also rectal contrast to delineate the boundaries of the rectum. No clear indication of any contained mass or obvious free fluid.

MRI Medical Transcription Sample Report #5

LUMBAR SPINE MRI:

Extra large flex body coil was used due to the patient’s body habitus. The patient was quite uncomfortable physically during the examination such that additional imaging was not able to be performed. We do have T1 and T2 weighted sagittal and axial imaging. There are no compression fractures of the vertebral bodies. The vertebral bodies themselves have no abnormal lytic or blastic changes suggested. There is disk desiccation of the lower three intervertebral disk spaces and then again at T12-L1 and T11-12.

L5-S1 suggests only a very minimal bulge. No axial images were completed through this region.

At L4-5, there is a large annular bulge and significant facet hypertrophy. There is also a midline and right recess disk protrusion, which appears to occupy most of the right recess and neural foramen with a small amount of space still remaining at the most superior aspect of the neural foramen. This soft tissue disease in concert with facet disease does appear to significantly compress that right crossing nerve root. In addition, this combination of bone and soft tissue disease produces a trilateral narrowing of the spinal canal, which is moderately significant. There is some mild left neural foraminal narrowing at this level, but it is not as great as the compromise to the right.

At L3-4, we again see trilateral narrowing of the spinal canal due to both disk and bony facet hypertrophy. Again, there is disk desiccation and some annular disk bulging at this level, which produces mild to moderate neural foraminal narrowing bilaterally. It is again greater to the right than the left.

At L2-3, there is no disk desiccation and there is only a minimal bulge. There is some very minimal facet hypertrophy. Still, there is some narrowing of the spinal canal. A component of this may be due to congenitally short pedicles.

The sagittal images also suggest some annular disk disease at T11-12, which protrudes to the central midline region. There also appears to be some facet hypertrophy bilaterally, though greater on the right. Axial images were not taken through this region, most likely due to the patient’s discomfort. Should there be radicular symptoms that are felt to be related to this T11-12 disk space, we would be happy to have the patient come back for additional views and do an addendum at a later date.

IMPRESSION:
1. No compression fractures, lytic or blastic changes to the vertebral bodies. No spondylolisthesis.
2. An element of what may be congenitally short pedicles, which narrows the foramen of the spinal canal somewhat.
3. Annular disk bulge with a midline and right recess disk broad-based protrusion with facet hypertrophy. This significantly compromises the right neural foramen and minimally to moderately compromises the left.
4. Annular bulge, which lateralizes more to the right than the left at L3-4.
5. There is an element of trilateral narrowing of the spinal canal both at L4-5 and at L3-4 in that order of severity due to this combination of bone and soft tissue disease.

MRI Medical Transcription Sample Report #6

MRI SCAN OF THE BRAIN WITH AND WITHOUT CONTRAST

DATE OF MRI:  MM/DD/YYYY

CLINICAL HISTORY: Focal speech deficits following admission for respiratory distress.

TECHNIQUE AND FINDINGS: Multiplanar sagittal, axial and coronal images were obtained through the brain prior to and following contrast administration. Inversion recovery images identify two focal areas of abnormal increased signal involving the left temporal lobe as well as the right occipital lobe. This shows abnormal signal, particularly involving the gyri. Following contrast administration, there is some evidence of enhancement to these areas without clear indication of any specific focal mass or mass effect. I believe these findings represent ischemic foci. Enhancement pattern is typical of what is known as luxury perfusion. Again, no mass effect noted. No clear indication to suggest any abnormal intracranial mass or abnormal vascularity such as an arteriovenous malformation.

IMPRESSION: Two focal areas of abnormal signal change. One appears in the left temporal lobe with specific focal gyral enhancement. Additional focus appears within the right occipital lobe region, again within the periphery with characteristic gyral enhancement. These findings would be consistent with an ischemic focus. Enhancement is typical of luxury perfusion, often seen in subacute infarcts. The remainder of the intracranial examination is unremarkable.