File name: “MR brain”
UNENHANCED [+AND CONTRAST ENHANCED+] HEAD MR
INDICATION:
[+Payable: Headache: headache, migraine – unspecified; Dementia: senile dementia, presenile
dementia – uncomplicated, Alzheimer disease, memory loss; Neoplasm: malignant lung
neoplasm or lymphoma; TIA& CVA: TIA, CVA, alteration of awareness or consciousness,
syncope & collapse, visual disturbance – unspecified, dizziness & giddiness, gait abnormality,
lack of co-ordination, skin sensation disturbance; Acute delirium; Seizure; Head injury (do
NOT say “trauma”); Syncope and collapse; Cerebral hemorrhage; Cerebral calcification;
Abnormal finding on a radiologic exam+]
[+Nonpayable: chronic sinusitis.+]
COMPARISON: []
TECHNIQUE: Unenhanced head MR was performed. [+An enhanced head MR was performed
following intravenous injection of (volume/type of IV contrast).+] [+The patient was scanned
within 24 hours of admission to the hospital.+]
INTERPRETATION:
Brain and CSF spaces: []
Pituitary gland and pineal: []
Vasculature: []
Paranasal sinuses: []
Nasal cavity and nasopharynx: []
Otomastoid findings: []
Bones and joints: []
Orbits: []
IMPRESSION:
[]
Dictated at []
File name: “MR brain for dementia”
UNENHANCED [+AND CONTRAST ENHANCED+] HEAD MR
INDICATION: Dementia. []
COMPARISON: []
TECHNIQUE: Unenhanced head MR was performed. [+An enhanced head MR was performed
following intravenous injection of (volume/type of IV contrast).+] [+The patient was scanned
within 24 hours of admission to the hospital.+]
INTERPRETATION:
Brain and CSF spaces: [+Atrophy: frontal = Pick, temporal = Alzheimer, cerebellar = alcohol,
mass, swelling, prior white or gray matter infarcts, demyelinating disease+] [+Subdural or
epidural hematoma, mass.+] [+Hydrocephalus; ventricle distortion, hemorrhage, mass.+]
[+Subarachnoid hemorrhage..+]
Pituitary gland and pineal: []
Vasculature: [+Anerysm, stenosis.+]
Paranasal sinuses: [+Sinusitis, mass+]
Nasal cavity and nasopharynx: [+Mass, lymphadenopathy, abscess, inflammation+]
Otomastoid findings: [+Skull fracture, fluid level in sinus, ear, mastoid air cells.+]
Bones and joints: []
Orbits: []
IMPRESSION:
[]
Dictated at []
File name: “MR brain for headache”
UNENHANCED [+AND CONTRAST ENHANCED+] HEAD MR
INDICATION: Headache. []
COMPARISON: []
TECHNIQUE: Unenhanced head MR was performed. [+An enhanced head MR was performed
following intravenous injection of (volume/type of IV contrast).+] [+The patient was scanned
within 24 hours of admission to the hospital.+]
INTERPRETATION:
Brain and CSF spaces: [+Atrophy: frontal = Pick, temporal = Alzheimer, cerebellar = alcohol,
mass, swelling, prior wh[+Brain mass (primary or metastatic tumor, abscess, AVM,
intraparenchymal hemorrhage, sarcoidosis), swelling (infiltrating tumor, encephalitis, severe
contusion/concussion, pseudotumor cerebri, stroke),, abnormal enhancement (tumor, sarcoidosis,
encephalitis, stroke, AVM, aneurysm). [+Extra-axial crescent (subdural hematoma, subdural
effusion from intracranial hypotension), lens (epidural hematoma), mass or masses (menigioma,
other primary tumors, metastatic disease), or enhancing meninges (meningitis both infectious
and malignant, intracranial hypotension, sarcoidosis).+] [+Subarachnoid hemorrhage.+]
[+Ventricular distension (hydrocephalus), fluid-level (hemorrhage), mass, or compression
(pseudotumor cerebri+.] [+Cerebellar tonsil position (Arnold Chiari malformation)+]
Pituitary gland and pineal: [+Mass, hemorrhage, abscess, cyst+]]
Vasculature: [+Focally enlarged intracranial artery (aneurysm, AVM). Absent filling or
significant stenosis (stroke). Venous filling defect (venous sinus thrombus). Abnormal
thickened or enhancing temporal arteries (temporal arteritis).+]
Paranasal sinuses: [+Sinus opacification, membrane thickening, or fluid level (sinusitis).+]
Nasal cavity and nasopharynx: [+Mass, lymphadenopathy, abscess, polyps.+]
Otomastoid findings: [Mastoid air cell opacification, membrane thickening, or fluid level
(mastoiditis).]
Bones and joints: [+Skull metastatic deposit. TMJ arthritis. Cervico-basilar and upper cervical
disc and facet disease.+]
Orbits: []
IMPRESSION:
[]
Dictated at []
File name: “MR brain for TIA”
UNENHANCED [+AND CONTRAST ENHANCED+] HEAD MR
INDICATION: [+Describe neurologic deficit+]
COMPARISON: []
TECHNIQUE: Unenhanced head MR was performed. [+An enhanced head MR was performed
following intravenous injection of (volume/type of IV contrast).+] [+The patient was scanned
within 24 hours of admission to the hospital.+]
INTERPRETATION:
Brain and CSF spaces: [+Atrophy: frontal = Pick, temporal = Alzheimer, cerebellar = alcohol,
mass, swelling, prior wh[+Brain mass (primary or metastatic tumor, abscess, AVM,
intraparenchymal hemorrhage, sarcoidosis), swelling (infiltrating tumor, encephalitis, severe
contusion/concussion, pseudotumor cerebri, stroke),, abnormal enhancement (tumor, sarcoidosis,
encephalitis, stroke, AVM, aneurysm). [+Extra-axial crescent (subdural hematoma, subdural
effusion from intracranial hypotension), lens (epidural hematoma), mass or masses (menigioma,
other primary tumors, metastatic disease), or enhancing meninges (meningitis both infectious
and malignant, intracranial hypotension, sarcoidosis).+] [+Subarachnoid hemorrhage.+]
[+Ventricular distension (hydrocephalus), fluid-level (hemorrhage), mass, or compression
(pseudotumor cerebri+.] [+Cerebellar tonsil position (Arnold Chiari malformation)+]
Pituitary gland and pineal: [+Mass, hemorrhage, abscess, cyst+]]
Vasculature: [+Focally enlarged intracranial artery (aneurysm, AVM). Absent filling or
significant stenosis (stroke). Venous filling defect (venous sinus thrombus). Abnormal
thickened or enhancing temporal arteries (temporal arteritis).+]
Paranasal sinuses: [+Sinus opacification, membrane thickening, or fluid level (sinusitis).+]
Nasal cavity and nasopharynx: [+Mass, lymphadenopathy, abscess, polyps.+]
Otomastoid findings: [Mastoid air cell opacification, membrane thickening, or fluid level
(mastoiditis).]
Bones and joints: [+Skull metastatic deposit. TMJ arthritis. Cervico-basilar and upper cervical
disc and facet disease.+]
Orbits: []
IMPRESSION:
[]
Dictated at []
File name: “MR brain for Stroke”
UNENHANCED [+AND CONTRAST ENHANCED+] HEAD MR
INDICATION: [+Describe neurologic deficit.+]
COMPARISON: []
TECHNIQUE: Unenhanced head MR was performed. [+An enhanced head MR was performed
following intravenous injection of (volume/type of IV contrast).+] [+The patient was scanned
within 24 hours of admission to the hospital.+]
INTERPRETATION:
Brain and CSF spaces: [+Atrophy: frontal = Pick, temporal = Alzheimer, cerebellar = alcohol,
mass, swelling, prior wh[+Brain mass (primary or metastatic tumor, abscess, AVM,
intraparenchymal hemorrhage, sarcoidosis), swelling (infiltrating tumor, encephalitis, severe
contusion/concussion, pseudotumor cerebri, stroke),, abnormal enhancement (tumor, sarcoidosis,
encephalitis, stroke, AVM, aneurysm). [+Extra-axial crescent (subdural hematoma, subdural
effusion from intracranial hypotension), lens (epidural hematoma), mass or masses (menigioma,
other primary tumors, metastatic disease), or enhancing meninges (meningitis both infectious
and malignant, intracranial hypotension, sarcoidosis).+] [+Subarachnoid hemorrhage.+]
[+Ventricular distension (hydrocephalus), fluid-level (hemorrhage), mass, or compression
(pseudotumor cerebri+.] [+Cerebellar tonsil position (Arnold Chiari malformation)+]
Pituitary gland and pineal: [+Mass, hemorrhage, abscess, cyst+]]
Vasculature: [+Focally enlarged intracranial artery (aneurysm, AVM). Absent filling or
significant stenosis (stroke). Venous filling defect (venous sinus thrombus). Abnormal
thickened or enhancing temporal arteries (temporal arteritis).+]
Paranasal sinuses: [+Sinus opacification, membrane thickening, or fluid level (sinusitis).+]
Nasal cavity and nasopharynx: [+Mass, lymphadenopathy, abscess, polyps.+]
Otomastoid findings: [Mastoid air cell opacification, membrane thickening, or fluid level
(mastoiditis).]
Bones and joints: [+Skull metastatic deposit. TMJ arthritis. Cervico-basilar and upper cervical
disc and facet disease.+]
Orbits: []
IMPRESSION:
[]
Dictated at []