Scan performed by: ................................... Position ............................... MRI Report Completed by: ....................... Position......................... MRI scanner make/model ................../................ MRI scan date: MRI scan start time: : MRI scan end time: : Part A Sequences performed T1 T2 T1-FS Plane Performed? Subjective assessment of quality Slice thickness (mm) Inter slice gap (%) FOV Performed? Subjective assessment of quality Slice thickness (mm) Inter slice gap (%) FOV Performed? Subjective assessment of quality Slice thickness (mm) Inter slice gap (%) FOV Contrast Axial No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes Sagittal No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes Coronal No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes Additional sequences No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes Good Satisfactory Inadequate Poor No Yes These reading can be collected from scan legend at a later stage.
Part D Other observations Site Mass observed Location of origin relative to uterus Number of masses Size of largest Signal Intensity T1 T2 T1-FS TUBAL No Yes Right Left Medial Lateral Other (describe) .................................... Length ………….. cm Width ………….. cm Transverse ..………… cm High Intermediate Low High Intermediate Low High Intermediate Low PARA-OVARIAN No Yes Right Left Medial Lateral Other (describe) .................................... Length ………….. cm Width ………….. cm Transverse ..………… cm High Intermediate Low High Intermediate Low High Intermediate Low BOWEL No Yes Small Sigmoid Rectum Other (describe) .................................... Length ………….. cm Width ………….. cm Transverse ..………… cm High Intermediate Low High Intermediate Low High Intermediate Low Normal Abnormal If abnormal, enhanced with contrast No Yes Presence of (abnormal) small bowel in pelvis No Yes Bowel thickening? Sigmoid/ rectum No Yes Mesenteric/ antimesenteric No Yes Mucosal/ submucosal No Yes BLADDER No Yes Dome Posterior Anterior Other (describe) .................................... Length ………….. cm Width ………….. cm Transverse .………… cm High Intermediate Low High Intermediate Low High Intermediate Low
Normal Abnormal If abnormal, bladder wall thickness Trigone [perpendicular to Lumen at thickest part of Trigone] ...…….. mm Dome, Midline ………….….......... mm Anterior wall, midline ……........ mm Bladder volume ................ ml OTHER (Please specify) No Yes Other (describe) .................................... .................................... Length ………….. cm Width ………….. cm Transverse ..………… cm High Intermediate Low High Intermediate Low High Intermediate Low Part E: Other observations Fluid observed No Physiological Yes Free fluid No Yes Loculated fluid No Yes Adhesions No Clearly seen Suspected Clearly seen? Organs implicated 1. ...................................................................... 2. ...................................................................... 3. ...................................................................... Suspected? Reason Distortion of margins Proximity of organs Other (specify) No Yes No Yes No Yes Further Notes