MRI Report

MRI Report: Clinical Information: - [include clinical indication for the MRI, such as presenting symptoms, suspected diagnosis, anatomical region of concern, or reason for referral – e.g. suspected spinal pathology, neurological symptoms, or TB spondylitis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) - [include relevant medical or surgical history pertinent to the MRI examination, such as history of tuberculosis, HIV status, trauma, previous neurosurgery, or chronic comorbidities seen in South African public/private settings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) Findings: - [include detailed description of imaging findings including anatomical structures assessed, abnormalities identified, location and extent of any pathology, and comparison to prior imaging if available – e.g. vertebral body collapse, spinal cord signal changes, brain lesions, meningeal enhancement, sinus abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) Impression: - [summarise key findings, overall clinical interpretation of the scan, and diagnostic considerations or certainty level – e.g. "Findings suggestive of tuberculous spondylitis with paraspinal abscess formation", or "No acute intracranial pathology identified"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) Recommendations: - [include any recommended further imaging (e.g. contrast-enhanced MRI, CT scan), referral to specialist services (e.g. neurology, orthopaedics, infectious diseases), biopsy for histological confirmation, follow-up imaging, or correlation with laboratory results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) Radiologist: - [include full name and qualifications of the reporting radiologist, e.g. Dr N. Mokoena, MMed Rad (D)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) - [include radiologist’s signature or digital attestation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) - [include date the report was finalised in DD/MM/YYYY format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or recommendations. Use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output. Leave the relevant placeholder or section blank if it is not explicitly mentioned. Use as many full sentences as needed to capture all the relevant information from the transcript.)