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SEER Training Modules

Example MRI Report 2

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MRI Consultation Report

Name: Ina Gateway
DOB: 01/10/41

10020231 mr018
abdomen/180-22-33

Referring Service, Clinic or Floor: _______________________

Date: 03/20/91

  • [_] Ambulatory
  • [_] Bed
  • [_] O2
  • [_] OR
  • [_] Wheelchair
  • [_] Portable
  • [_] Isolation

Procedures Requested: MRI Abdomen

Primary Diagnosis (required): _______________________

Outpatient ICD-9 Code: _______________________

Clinical History Pertinent to this Radiology Consultation (required)

(Include precautions: diabetes, allergies, etc.) Serum Creatinine or BUN for CT, IVP, Angio

Requesting Physician Name: _______________________

Requesting Physician Phone: _______________________

Attending Physician Name: _______________________

Attending Physician Phone: _______________________

Report will be sent to Physician's Office, Clinic, Floor and Medical Records

Address (Street, City, State): _______________________

Date and Time Procedure Completed: _______________________

Technologist I.D.: _______________________

Part Exam: _______________________

Film Count:

  • 7
  • 8
  • 10
  • 11
  • 14
  • PCR

KVP Fluoro
Time
MAS

Distance MR

Sequences

Contrast Supplies and Comments: _______________________

Radiology Consultation Report

MRN: 180-22-33
Name: Ina Gateway
Proc: MRI of abdomen (03/20/91)

MRI was performed on a GE Sigma 1.5 Tesla MRI machine. Axial images with TR of 500 and TE 15, slice thickness of 5 mm were taken from the dome of the diaphragm to the iliac wings. Also taken were axial images with TR 2000 and TE 30/80 with 5-mm thick sections. Coronal sections with TR 500 and TE 15. In addition, axial sections with TR 10 and TE 2.9 with 5-mm thick sections were also included.

Conclusion:

  1. A left suprarenal perirenal mass with mixed intermediate signal on T1 and T2 with areas of peripheral high signal on T1 and T2. The mass measures approximately 2.5 x 2 x 2 cm. This most likely represents a neuroblastoma with hemorrhage in the left adrenal.
  2. No evidence of liver or spleen involvement or metastases.
  3. The mass is displacing the left kidney posteriorly, however.
  4. No identified skin involvement.

John Doe, M.D.
Date: 03/20/91