Date : 00.00.00
Name of the Patient : Abc Xyz T. Khlmn / F / 37 yrs.
Referred by : Dr. Abc Xyzpadia.
Examination : M.R.I. of the Left Thigh.
CLINICAL PROFILE :
C/O backache with pain radiating to the LLE with paresthesias since 4-5 months.
H/O being operated for fibrous dysplasia (with bone grafting) upon the left femur 4 years ago.
M.R.I. of the left thigh was performed using the following parameters :
4 mm thick T1 Weighted sagittal images.
4 mm thick T1 Weighted and T2 Weighted coronal images (with fat saturation).
10 mm thick T1 Weighted and T2 Weighted axial images (with fat saturation).
Susceptibility artifacts are noted in the proximal shaft of the left femur, the sequelae of previous surgery. Tract of the previous implant is noted in the head and neck of the left femur. Susceptibility artifacts are also noted in the soft tissues along the lateral margin of the proximal left femur. The muscles around the proximal left thigh appear slightly atrophied as compared to the right.
No obvious mass lesion is identified on this study. No vascular encasement is noted. Ill-defined, hyperintense signal on the T2 Weighted images in the vastus lateralis muscle on the left, posteriorly is the sequelae of previous surgery.
The visualized right thigh is unremarkable.
Screening T1 Weighted sagittal images of the lumbo-sacral spine do not reveal any significant feature of note.
1. Post-operative status within the proximal shaft of the left femur and the soft tissues along the lateral margin of the proximal left femur which is the sequelae of previous surgery.
2. Slight atrophy of the muscles around the left thigh as compared to the right.
3. No other significant abnormality is detected on this study.
7th December 0000.
Dear Dr. Abc Xyzapadia,
We have reviewed the MRI of the left hip joint of Ms. Fatima Khatri, female, aged 37 years.
The rounded lesion identified by you, inferior to the greater trochanter of the left femur at the neck-shaft junction, may either be a post-operative change, a residual lesion or may be due to the tract of the previous implant through the head and neck of the left femur. It is difficult to establish whether this is a quiescent lesion or a recurrent, active lesion. There is however, no cortical erosion or extension of the lesion into the adjacent soft tissues identified on this study. The susceptibility artifacts at the operative site also contribute to the uncertainty. There is also no previous preoperative scan available for comparison.
Thanking you once again for your kind reference,