Diagnostic Radiologist-Vorlage
Wrist MRI
Eine professionelle Diagnostic Radiologist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
A Wrist MRI report template is a structured document used by diagnostic radiologists to detail the findings of a wrist MRI scan. This template provides a comprehensive framework for documenting bone structures, joints, ligaments, tendons, and soft tissues. The template ensures all relevant aspects of the wrist are assessed, including the distal radius and ulna, carpal bones, TFCC, and extensor and flexor compartments. When used with Heidi, the AI scribe, the radiologist's dictated findings are automatically populated into the correct sections, saving time and improving accuracy. This example report, dated 1 November 2024, showcases how the template is used to document a wrist MRI examination.
Vorlagenvorschau
**Clinical Information:**
Patient presents with left wrist pain following a fall. Clinical suspicion of scaphoid fracture.
**Findings:**
**Bones:**
Distal radius and ulna: No fracture or dislocation identified. Mild degenerative changes at the ulnar styloid.
Carpal bones: Scaphoid demonstrates a non-displaced fracture at the waist. Lunate, triquetrum, and other carpal bones are unremarkable.
Metacarpal bases: No fractures or dislocations identified.
**Joints and Alignment:**
Radiocarpal joint: Normal alignment. No significant joint effusion. Cartilage appears intact.
Distal radio-ulnar joint: Normal alignment. No significant joint effusion. Cartilage appears intact.
Midcarpal joint: Normal alignment. No significant joint effusion. Cartilage appears intact.
**TFCC:**
Triangular fibrocartilage complex (TFCC): No tear identified.
**Ligaments:**
Scapholunate ligament: No evidence of tear.
Lunotriquetral ligament: No evidence of tear.
**Extensor Compartment:**
Extensor compartments: No tendon abnormalities.
**Flexor Compartment:**
Carpal tunnel: No evidence of carpal tunnel syndrome. Median nerve appears normal.
**Soft Tissues:**
No soft tissue masses or muscle findings identified.
**Additional Findings:**
Small amount of fluid in the radiocarpal joint.
**Impression:**
1. Non-displaced fracture of the scaphoid waist.
2. Mild degenerative changes at the ulnar styloid.
3. Small amount of radiocarpal joint effusion.
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