Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic
Sample Name: MRI Knee - 5

Description: MRI right knee without gadolinium
(Medical Transcription Sample Report)

EXAM:MRI RIGHT KNEE WITHOUT GADOLINIUM

CLINICAL:This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.

FINDINGS:
Examination was performed on 8/3/05

Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.

There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.

There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.

Normal posterior cruciate ligament.

Normal medial collateral ligament.

There is a strain of the popliteus muscle and tendon without complete tear.

There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).

Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.

There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.

The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.

IMPRESSION:
Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.

Mild anterior cruciate ligament interstitial sprain.

There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.


Keywords: orthopedic, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples