ke/bv
Date : 00.00.00

Name of the Patient : Abc XyzA. Divlmn / F / 58 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.

CLINICAL PROFILE:

C/O neckpain with radiating pain and weakness of the RUE since 2 years.
H/O right mastectomy. Received 6 cycles of chemotherapy.

EXAMINATION :

M.R.I of the cervical spine was performed using the following parameters :

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T1 Weighted and T2 Weighted axial images.

4 mm thick T1 Weighted and STIR coronal images.

OBSERVATION :

Enlarged supra clavicular lymphnodes are visualized along the course of the brachial plexus on the right side (scans 106.18 to 20, 109.16 to 109.19). Note is also made of enlarged deep cervical lymph nodes.

Suspicious thickening of the right C6, C7 and C8 nerve roots is visualized (scans 106.15, 106.18, 109.20).

Multiple lesions are seen in the lung fields bilaterally of varying size and would represent metastasis in the given clinical setting.

An intermediate signal intensity lesion on the T1 Weighted images is seen in the region of the right axilla (scans 106.21-23) may represent local recurrence/metastasis.


Small posterior disc bulges are seen at the C3-C4 and C4-C5 levels.

The cervical and upper dorsal intervertebral discs show loss of water content.

The cervical vertebral bodies show fatty changes suggestive of osteoporosis. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.

The cervical spinal cord shows normal signal intensity.

The atlanto-axial region and the cervico-medullary junction are unremarkable.

IMPRESSION :

1. Enlarged deep cervical lymph nodes and enlarged supra clavicular lymphnodes along the course of the brachial plexus on the right side may represent metastasis in the given clinical setting.

2. Multiple metastasis in both lung fields.

3. No significant abnormality is seen in the cervical spine.