Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Radiology
Sample Name: MRI Orbit/Face/Neck

Description: MRI Orbit/Face/Neck with MR Angiography of the Head - An infant with facial mass
(Medical Transcription Sample Report)

EXAM: MRI orbit/face/neck with and without contrast; MR angiography of the head

CLINICAL HISTORY: 1-day-old female with facial mass.

TECHNIQUE:
1. Multisequence, multiplanar images of the orbits/face/neck were obtained with and without contrast. 0.5 ml Magnevist was used as the intravenous contrast agent.
2. MR angiography of the head was obtained using a time-of-flight technique.
3. The patient was under general anesthesia during the exam.

FINDINGS: MRI orbits/face/neck: There is a pedunculated mass measuring 5.7 x 4.4 x 6.7 cm arising from the patient's lip on the right side. The mass demonstrates a heterogeneous signal. There is also heterogeneous enhancement which may relate to a high vascular tumor given the small amount of contrast for the exam. The origin of the mass from the upper lip demonstrates intact soft tissue planes.

Limited evaluation of the head demonstrates normal appearing midline structures. Incidental note is made of a small arachnoid cyst within the anterior left middle cranial fossa. The mastoid air cells on the right are opacified; while the left demonstrates appropriate aeration.

MR angiography of the head: Angiography is limited such that the vessel feeding the mass cannot be identified with certainty. The right external carotid artery is noted to be asymmetrically larger than the left, the phenomenon likely related to provision of feeding vessels to the mass. There is no carotid stenosis.

IMPRESSION:
1. The mass arising from the right upper lip measures 5.7 x 4.4 x 6.7 cm with a heterogeneous appearance and enhancement pattern. Hemangioma should be considered in the differential diagnosis as well as other mesenchymal neoplasms.
2. MR angiography is suboptimal such that feeding vessels to the mass cannot be identified with certainty.

Keywords: radiology, orbit, face, neck, multisequence, multiplanar, time-of-flight, angiography of the head, facial mass, upper lip, feeding vessels, angiography, head, mri, mass,
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Transcribed Medical Transcription Sample Reports and Examples