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 Shoulder - 2

Description: A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.
(Medical Transcription Sample Report)

EXAM:MRI LEFT SHOULDER

CLINICAL:This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.

FINDINGS:

The patient was scanned in a 1.5 Tesla magnet.

There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.

There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.

Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.

There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.

Normal anterior and posterior glenoid labra.

Normal supraspinatus, infraspinatus, and teres minor tendons.

Normal muscles of the rotator cuff and there is no muscular atrophy.

There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.

Normal acromioclavicular articulation.

IMPRESSION:

Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.

Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.

Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.

Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.

Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte.

Keywords: orthopedic, insertion of the subscapularis, supraspinatus infraspinatus and teres, infraspinatus and teres minor, axial t series, supraspinatus infraspinatus, teres minor, minor tendons, posterior superior, biceps tendon, rotator, capsule, glenohumeral, tendon, series, superior,
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