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/00002 Date : 00.00.00

Name of the Patient : Abc Xylmn / F / 74 yrs.
Referred by : Dr. Abc Xyzlal.
Examination : M.R.I. of the Pelvis & Lumbo-sacral Spine.

CLINICAL PROFILE :

C/O menorrhagia.
C/O urinary incontinence and renal insufficiency.
Known diabetic/hypertensive.

EXAMINATION :

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

6 mm thick T1 Weighted and T2 Weighted (with fat saturation) axial and sagittal images.

6 mm thick T1 Weighted coronal images.

M.R.I of the lumbo-sacral spine was performed using the following parameters:

5 mm thick T1 Weighted and T2 Weighted sagittal images.

5 mm thick T2 Weighted axial images.

SOME IMAGES SHOW PATIENT MOTION.

OBSERVATION :

PELVIS:

The uterus is seen to be bulky. The endometrial cavity is widened and shows a hyperintense signal on the T2 Weighted images. There is a break of the junctional zone at the posterior aspect of the uterus (se/im 103.10). The myometrium shows a few areas of hyperintensity on the T2 Weighted images.
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A Foleys catheter is noted in the urinary bladder. There is slight thickening of the wall of the urinary bladder. The utero-vesical pouch appears to be well maintained.

The ischio-rectal fossae on either side appear normal.

There are no abnormally enlarged pelvic lymph nodes identified. No obvious vascular anomaly is noted. There is no free fluid in the pelvis.

LUMBO-SACRAL SPINE:

There is Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra. Also seen is retroplacement of the L5 vertebra over the S1 vertebra.

Posterior and far lateral (extraforaminal) disc bulges are seen at the L2-L3, L3-L4, L4-L5 and L5-S1 levels. There is mild bilateral neural foraminal narrowing at these levels.

The L4-L5 facet joints show hypertrophic degenerative changes. The L3-L4 and L5-S1 facet joints show mild degenerative changes.

A large Schmorls node is seen at the superior aspect of the L5 vertebral body.

The lumbar intervertebral discs show loss of water content. The lumbar vertebral bodies show areas of fatty replacement of normal marrow.

The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L2 level and the thecal sac terminates at the S1 level.
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- 3 - Scan-00002


The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :

14.0 mm at L1-L2
15.0 mm at L2-L3
15.0 mm at L3-L4
10.0 mm at L4-L5
8.0 mm at L5-S1.

IMPRESSION :

1. A bulky uterus with a widened endometrial cavity and a break in the junctional zone as decribed may be the result of an endometrial carcinoma.

2. Grade I spondylolisthesis of the L4 vertebra over the L5 vertebra.

3. Posterior and far lateral (extraforaminal) disc bulges at the L2-L3, L3-L4, L4-L5 and L5-S1 levels.

4. Hypertrophic facetal arthropathy at the L4-L5 level.







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finance@medmantra.com (Regular User) MRI Reports Sun, 27 Dec 2015 16:48:00 +0000