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ke/sb/rg
Date : 00.00.00

Name of the Patient : Abc XyzSulmn / F / 34 yrs.
Referred by : Dr. Abc Xyz Modi / Dr. Abc Xyzejpal.
Examination : M.R.I. of the Abdomen.

CLINICAL PROFILE :

Appendectomy done on 00.00.00 with discharge from the operative site with pain and loss of weight (around 8 Kg.) since then.

EXAMINATION :

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

7 mm thick T1 Weighted and T2 Weighted axial images.

7 mm thick T1 Weighted and STIR coronal images (with fat saturation).

5 mm thick T2 Weighted (with fat saturation) sagittal images.

OBSERVATION :

There are post-operative changes in the subcutaneous fat of the anterior abdominal wall on the right side, inferiorly.

A sinus tract which is hypointense on the T1 Weighted images and turns hyperintense on the T2 Weighted and STIR images is seen to extend from the surface of the skin at a level just below the umbilicus to the right of the midline and extends through the subcutaneous fat involving the internal and the external oblique muscles of the abdominal wall. The internal and external oblique muscles on the right side at the site of surgery appear bulky as compared to the left and show a hyperintense signal on the T2 Weighted and STIR images suggesting of edema/inflammatory tissue/post-operative changes.

Signal change in the subcutaneous fat is noted for about 5 cms supero-inferiorly from the site of the sinus.

No obvious collection is seen on this study.
..2/.



- 2 - scan-00003


The rectus abdominus muscle on the right side appears slightly atrophic as compared to the left.

The visualized kidneys are normal in size and shape (mild fullness of the right pelvicalyceal system is noted).

No lymphadenopathy is detected. There is no evidence of free fluid within the abdomen.

A bowel loop is noted in the close relation to the anterior abdominal wall, on the right.

IMPRESSION :

1. Post-operative status.

2. A sinus tract extending from the surface of the skin at the operative site, just below the umbilicus to the right of the midline and involving the external and internal oblique muscles as described. No collection is noted.


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    • Interventional Pain Procedure Templates
    • The Ultimate Guide to Rapid Reporting for FRCR 2B
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