---
# System prepended metadata

title: 2019 MRI第一份報告
tags: [MRI]

---

[MRI LINK](https://www.dicomlibrary.com/meddream/?study=1.3.6.1.4.1.44316.6.102.1.20251126213736531.64938086562236757560) 

# 2019 MRI
* 主治醫師:吳永燦DOC31149 部分負擔:
* 就診別:門診
* 病歷號:2878923 診別:下午診
* 36 性別:男
* 生日: 0720729
* 看診日期:1090417 健保卡號 看診區域: 內湖診區
* 申請科別:復健醫學
* 單號:0033738531
* 申請日期:1090417
* 申請時間:14:01:10

三軍總醫院
申請醫師:吳永燦
部位:
MUSCULOSKELETAL MRI R't
MUSCULOSKELETAL MRI 1. KNEE JOINT
©序號 檢驗項目 檢驗名稱
R80001 MRI without cont rast
問題/診斷:
M2240:未明示側性膝部骨軟骨軟化
M7121:右側膝部區滑膜囊腫[(Baker()]
主訴:

* 2020/04/17: The pain of right knee still on and off.
* 2020/04/17: ESWT did not work.
* 2020/03/13: Pain persisted.

posterior knee pain for several weeks
pain and soreness over posterior knee.
palpable mass-like lesion over right knee.
Trauma: several years ago.
0: VAS: 4
ROM of knee, right: pain over end range flexion.
PGT (+)
PDT : +1 -
tende/: R't posterolateral knee pain for months.
rness over posteior knee fossa.
## MRI Findings: 
1. The patellofemoral joint shows fraying cartilage surface in the lateral patellar facet inferior pole (Se:4; Im:8). 
2. Note a synovial plicae over the medial recess of patellofemoral joint.
3. Small amount of effusion with synovial thickening in the suprapatellar bursa, tibiofemoral joint and patella-femoral joint is noted, favor synovitis.

MRI發現：
> 
> * 髕股關節在外側髕骨小窩下極顯示軟骨表面有磨損。
> * 髕股關節內側凹處觀察到滑膜襞。
> * 髕股關節、脛股關節和髕骨股骨關節均觀察到少量滲液和滑膜增厚，懷疑為滑膜炎。
## recommand: 
1. There is no Baker's cyst or focal mass lesion over the popliteal fossa. Suggest clinical correlation. 
2. **Chronic insufficiency of the PCL is suspected.**
3. **Fraying chondral surface of the patellofemoral joint as described.**
4. For other details, please see above descriptions.

> 建議：
> * 未發現貝克囊腫或腘窩處的局部腫塊，建議臨床相關性評估。
> * 懷疑慢性後十字韌帶(PCL)功能不全。
> * 如上所述，髕股關節軟骨表面磨損。
### Assessment : 
Strain of L't biceps tendon, lateral part;
> 後方外側肌肉為股二頭肌?
> 
Chronic insufficiency of the PCL
> （慢性後十字韌帶功能不全）：這是指患者的後十字韌帶（PCL）長期存在功能不足的情況。後十字韌帶是膝關節中重要的結構之一，負責穩定膝關節的前後移動。功能不全可能源於長期磨損、損傷或不當治療。
## Plan: 
Arrange MRI of right knee (Dr. Chang informe him before)
certificate home program exercise education. OPD follow-up
### 部位:
MUSCULOSKELETAL MRI R't
MUSCULOSKELETAL MRI 1. KNEE JOINT
