sb/ke/nl/rg.
Date : 00.00.00
Name of the Patient : Abc Xyz Plmn / M / 61 yrs.
Referred by : Dr. Abc Xyzabhat.
Examination : M.R.I. of the Skull Base & Neck.
CLINICAL PROFILE :
H/O cold and cough with mild fever 15 days back with tonsillitis. Recovered.
Now C/O difficulty in chewing, swallowing, close eyes fully, dysarthria and numbness of lower jaw.
EXAMINATION :
M.R.I of the skull base and neck was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted (with fat saturation) axial images.
4 mm thick T1 Weighted coronal images.
5 mm thick T1 Weighted sagittal images.
MR cisternogram was obtained in the coronal plane.
OBSERVATION :
There is slight hypertrophy of the palatine tonsils bilaterally.
The parapharyngeal spaces, prevertebral space and the carotid sheaths are unremarkable on either side.
The visualized salivary glands are also unremarkable.
There are no abnormally enlarged cervical lymph nodes noted in the visualized neck.
The seventh and eighth cranial nerve complex is unremarkable.
The visualized brainstem shows normal signal intensity.
Prominent cerebellar folia are noted bilaterally.
IMPRESSION :
Slight hypertrophy of the palatine tonsils bilaterally.
Mild cerebellar atrophy.