UNENHANCED [+AND CONTRAST ENHANCED+] BRAIN MRI
INDICATION:
[+Payable: Headache: headache, migraine; Dementia: Alzheimer disease, memory loss;
Neoplasm: brain unspecified, malignant neoplasm brain (primary or secondary), benign
neoplasm (brain); TIA& CVA: Transient cerebral ischemia, CVA, altered mental status,
transient alteration of awareness, syncope & collapse, visual disturbance, dizziness & giddiness,
gait abnormality, aphasia, skin sensation disturbance; Head injury (do NOT say “trauma”);
Pituitary disorder, tremor (NEC), multiple sclerosis, central origin vertigo, acoustic nerve
disorder.+]
[+Nonpayable: change in mental status {even though “altered mental status” and “transient
alteration of awareness” are both payable!}, hearing loss.+]
COMPARISON: []
TECHNICAL INFORMATION: Axial, coronal, and sagittal unenhanced images were obtained.
[+An enhanced brain 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 parenchyma: []
Extra-axial space: []
Subarachnoid space: []
Ventricular system: []
Intracranial vessels: []
Pituitary gland and sella: []
Skull and extra-cranial structures: []
IMPRESSION:
[]
Dictated at []
DAN CAMACHO’S TEMPLATE
File name: “MR head”
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:
Skull and cervical spine: []
Pituitary gland and pineal: []
Paranasal sinuses: []
Orbits: []
Nasal cavity and nasopharynx: []
Otomastoid findings: []
Vasculature: []
Brain and CSF spaces: []
IMPRESSION:
[]
Dictated at []
RADREPORT.ORG TEMPLATE WHICH INCLUDES HEAD AND BRAIN
Clinical History
* Medical history
* Risk factors
* Allergies, if relevant
* Reason for exam, including medical necessity: [headache | stroke |
dizziness | trauma]
Imaging Technique
* Time of image acquisition
* Imaging device [MR, CT]
* Image acquisition parameters, such as device settings, patient
positioning, interventions (e.g., Valsalva maneuver)
* Contrast materials and other medications administered (including name,
dose, route, and time of administration)
* Radiation dose
Comparison
* Date and type of previous exams reviewed, if applicable
Observations
* Extra axial spaces: [normal in size and morphology for the patient's
age* | widened]
* Hemorrhage: [none* ; subdural ; subarachnoid; epidural,
intraventricular, parenchymal]
* Ventricular system: [normal in size and morphology for the patient's
age* | enlarged | small]
* Basal cisterns: [normal* | enlarged | small]
* Cerebral parenchyma: [normal*; microvascular changes; infarction;
encephalomalacia; gliosis; hemorrhage]
* Midline shift: [none* | leftward shift | rightward shift]
* Cerebellum: [normal*]
* Brainstem: [normal*]
Other:
* Calvarium: [normal*; non-depressed fracture; depressed fracture;
osteolysis; sclerosis]
* Vascular system: [normal* | vascular calcifications (CT) | appropriate
arterial and dural sinus flow voids (MR)]
* Visualized Paranasal sinuses: [clear* | scattered mild inflammatory
mucosal thickening]
* Visualized Orbits: [normal*]
* Visualized upper cervical spine: [normal*]
* Sella and skull base: [normal* | partially empty sella | left/right
mastoid air cell fluid]
Summary (or Impression)
* An itemized list of key observations, including any recommendations.