Generated Narrative: Composition Composition-knee-mri-example Language: en Profile: Composition: Imaging Report Document DiagnosticReport Reference: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 identifier: http://citymedial-imagecenter.org//123456 status: Final type: Imaging Report V0.0.1 category: Diagnostic imaging study date: 2021-01-01 00:00:00+0000 author: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 title: MRI LEFT KNEE custodian: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 event Details - Reference * Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 event Details - Reference * Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
Axial PD fat sat, coronal T1, coronal PD fat sat, coronal T2 fat sat, sagittal PD, and sagittal PD fat sat images were performed
Evaluate medial left knee pain. Injured playing football 3 weeks ago. Positive Lachman test. Evaluate ACL tear. Evaluate for meniscal tear
Requested imaging studies information Document
Evaluate medial left knee pain. Injured playing football 3 weeks ago. Positive Lachman test. Evaluate ACL tear. Evaluate for meniscal tear.
Injured playing football 3 weeks ago.
None utilized.
None available
FLUID: Moderate effusion. MENISCI: Medial: No evidence of a tear. Lateral: Peripheral vertical tear in the posterior horn of the lateral meniscus at the ligament of Wrisberg attachment. CRUCIATE LIGAMENTS: Complete tear of the ACL, which is torn in the mid substance. The posterior cruciate ligament is intact. COLLATERAL LIGAMENTS: Grade 1 to grade 2 MCL sprain. There is edema in the deep fibers, as well as some in the in the superficial fibers and in the adjacent soft tissues. Edema extends anteriorly to the region of the medial patellofemoral ligament attachment to the adductor tubercle where the injury is intermediate grade in character. The lateral collateral ligament complex is intact. Edema is noted in the popliteus muscle belly and muscle-tendon junction as well as the popliteal fibular ligament region also reflective of an intermediate grade injury. EXTENSOR MECHANISM: Intact. CARTILAGE: Patellofemoral compartment: No chondral defect or area of high-grade chondral loss. Medial tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. Lateral tibiofemoral compartment: No chondral defect or area of high-grade chondral loss. BONE MARROW: Bone marrow contusions are seen in the posterior medial and lateral proximal tibia as well as the mid lateral femoral condyle extending anteriorly. There is a contusion in the anterior lateral proximal tibia and as well in the proximal fibula. There is an additional contusion along the inferior pole of the patella.
1. Moderate effusion. 2. Peripheral vertical tear in the posterior horn of the lateral meniscus at the ligament of Wrisberg attachment. 3. Complete tear of the ACL. 4. Grade 1 to grade 2 MCL complex sprain as described above. 5. Edema extends anteriorly to the region of the medial patellofemoral ligament attachment to the adductor tubercle where the injury is intermediate grade in character. Edema is noted in the popliteus muscle belly and muscle tendon junction as well as the popliteal fibular ligament region also reflective of an intermediate grade injury. 6. Bone marrow contusions are seen in the posterior medial and lateral proximal tibia as well as the mid lateral femoral condyle extending anteriorly. There is a contusion in the anterior lateral proximal tibia and as well in the proximal fibula. There is an additional contusion along the inferior pole of the patella.
None.
Generated Narrative: ImagingStudy 1 Profile: ImagingStudy: General identifier: Study Instance UID/999.999.3859744 status: Available modality: Magnetic Resonance subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 started: 2011-01-01 referrer: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 series uid: 999.999.94827453 modality: Magnetic Resonance description: Axial PD fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.9 unknown 1.2.840.10008.5.1.4.1.1.6.1: 1.2.840.10008.5.1.4.1.1.6.1 8 series uid: 999.999.94827454 modality: Magnetic Resonance description: Coronal T1 Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.21 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 20 series uid: 999.999.94827455 modality: Magnetic Resonance description: Coronal PD fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.7 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 6 series uid: 999.999.94827456 modality: Magnetic Resonance description: Coronal T2 fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.11 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 10 series uid: 999.999.94827457 modality: Magnetic Resonance description: Sagital PD Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.15 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 14 series uid: 999.999.94827458 modality: Magnetic Resonance description: Sagital PD fat sat Instances - Uid SopClass Number * 999.999.133.1996.1.1800.1.6.17 unknown 1.2.840.10008.5.1.4.1.1.3.1: 1.2.840.10008.5.1.4.1.1.3.1 16
Generated Narrative: Patient Patient-knee-mri-example Profile: Patient: Imaging John Smith Male, DoB: 1995-05-05 ( Medical Record number: 12345 (use: usual, ))
Generated Narrative: Practitioner referrer Profile: Practitioner (EU base) name: NationalRadMusculoskeletal
Generated Narrative: Organization Organization-knee-mri-example name: City Medical Imaging Center
Generated Narrative: ServiceRequest ServiceRequest-knee-mri-example Profile: ServiceRequest: Imaging Order status: Draft intent: Order category: Imaging (procedure) subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
Generated Narrative: Procedure ImProcedure-knee-mri-example Profile: Procedure: Imaging Acquisition status: Completed code: MRI of the knee subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
Generated Narrative: Condition ImImpression-knee-mri-example Profile: Condition: EU Condition clinicalStatus: active subject: Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000
Generated Narrative: Observation ImFinding-knee-mri-example Profile: Observation: Imaging Finding status: Final code: Clinical finding effective: 1993-11-29 12:36:56+0000 value: Complete tear of the ACL, which is torn in the mid substance
Complete tear of the ACL, which is torn in the mid substance
Generated Narrative: DiagnosticReport DiagnosticReport-knee-mri-example Profile: DiagnosticReport: Imaging Report Imaging Report V0.0.1 (Diagnostic imaging study) Subject Not done yet Reported 2021-01-01 00:00:00+0000 Performer Bundle: type = document; timestamp = 1993-11-29 12:36:56+0000 Report Details