sb/ke/nl/rg.
Date : 00.00.0000
Name of the Patient : Abc XyzF. Blmn / M / 22 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Right Shoulder.
CLINICAL PROFILE :
C/O pain in the right shoulder joint with swelling and inability to lift the RUE since 2-3 days, following some exercises.
EXAMINATION :
M.R.I of the right shoulder was performed using the following parameters :
4 mm thick T1 Weighted, GRASS and STIR axial images.
4 mm thick T1 Weighted sagittal images.
4 mm thick T1 Weighted, Proton, T2 Weighted and STIR coronal images.
OBSERVATION :
There is seen an ill-defined, hyperintense signal on the GRASS and STIR images in the anterior half of the deltoid muscle, the supraspinatus muscle and to a much lesser degree in the infraspinatus muscle. This lesion appears iso to slightly hyperintense to the normal muscle on the T1 Weighted images. The supraspinatus muscle and the anterior half of the deltoid muscle appear slightly increased in bulk. No signal change is noted along the tendinous insertion of the supraspinatus muscle. No obvious tear of the tendinous insertion of the supraspinatus muscle is noted.
The head of the right humerus shows normal contour and the head and upper shaft of the right humerus show normal signal intensity. The visualized scapula appears normal. The glenoid labrum is unremarkable.
..2/.
- 2 - Scan-00005
The articular cartilage of the head of the right humerus appears normal.
There is no evidence of fluid in the subdeltoid bursa.
There is no obvious bone erosion or destruction seen.
The acromio-clavicular joint is normal.
The visualized axilla is unremarkable.
Minimal fluid is noted in the gleno-humeral joint and along the bicipital tendon.
IMPRESSION :
The MRI features are suggestive of :
1. Altered signal in the anterior half of the deltoid muscle, the supraspinatus muscle and to a much lesser degree in the infraspinatus muscle as described is not specific for a single etiology. These changes may be post-traumatic in etiology and may represent partial tear/edema, in the given clinical setting. The possibility of an infective/inflammatory etiology or a neoplasm seems less likely.
2. Fluid along the bicipital tendon and in the gleno-humeral joint.