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 Brain - Lyme Disease

Description: A middle-aged male with increasing memory loss and history of Lyme disease.
(Medical Transcription Sample Report)

This is a middle-aged male with increasing memory loss and history of Lyme disease.

FINDINGS:
There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size. The lesion extends into the left cavernous sinus along the inferior edge of the C3 segment of the left cavernous carotid artery obscuring the left cranial nerves III, IV and VI. The V1 and V2 branches however can be identified. There is intense enhancement of this lesion following gadolinium augmentation. There is a focal central area of nonenhancement which measures approximately 4mm in diameter. There is right-sided deviation of the infundibulum with mild convex bowing of this mass lesion into the suprasellar cistern, however, there is no impingement upon the optic chiasm. There is pressure erosion of the floor of the sella turcica bulging into the sphenoid sinus without a demonstrated cortical destruction or invasion of the sphenoid sinus.

The lesion most likely represents a macroadenoma. The intense enhancement of the central area of hypointense signal raises the possibility a calcification suggesting a differential diagnosis of a late onset craniopharyngioma. The lesion is not considered consistent with a meningioma. CT imaging would be of benefit for exclusion of calcification.

Normal flow within the carotid and vertebrobasilar circulation and there is no demonstrated aneurysm of the Circle of Willis.

Normal cerebral hemispheres and normal cortical gray matter and white matter tracks. There are no white matter hyperintensities. There is normal enhancement of the dural sinuses and cortical veins. There is no enhancing intraaxial or extraaxial mass lesion.

Normal basal ganglia and thalami. Normal internal and external capsules.

Normal midbrain, pons and medulla and a normal brainstem cervical cord junction.

Normal vermis and cerebellar hemispheres.

Normal calvarium. There is a 1.5cm retention cyst of the posterior wall of the left maxillary antrum. The paranasal sinuses are normal.

Normal temporal bones.

Normal central skull base.

Normal clivus and craniovertebral junction.

IMPRESSION:
Large intrasellar mass lesion with probable invasion of the left cavernous sinus. See above for size, morphology and pattern of enhancement. Differential considerations include a macroadenoma of the pituitary gland versus a craniopharyngioma. CT imaging is recommended for assessment of possible calcifications.

Retention cyst of the left maxillary antrum.

Normal supratentorial brainstem and posterior fossa.

Keywords: radiology, increasing memory loss, intrasellar mass lesion, memory loss, sella turcica, cavernous sinus, sphenoid sinus, ct imaging, white matter, retention cyst, maxillary antrum, lyme disease, mass lesion, disease, cavernous, cortical, mass, lesion,
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