CT Report Samples (4)

CT Abdomen Report #1

PATIENT NAME: Debra Jones
ID NUMBER: 123456
REFERRING PHYSICIAN: Harry Richard, M.D.
REFERRING PHYSICIAN’S FAX: 305-123-4567
DATE OF SERVICE: 01/01/11
D.O.B.:

 

CT OF THE UPPER ABDOMEN WITH CONTRAST:

CLINICAL HISTORY: Follow-up aneurysms.

TECHNIQUE: CT was performed of the upper abdomen following the administration of IV contrast utilizing standard protocol. The current study is compared to a prior CT examination of the abdomen from 03/08/05 and a prior MRI of the upper abdomen from 09/07/05.

FINDINGS:No focal liver lesions are identified. There is mild dilatation of the common bowel duct and intrahepatic biliary radicals. This was present on the previous study. It appears unchanged. There is no evidence of splenic enlargement. The spleen is imaged in the splenic arterial phase and is therefore inhomogeneous.

The adrenals are not enlarged. No intrarenal mass is identified.

There was no visible pancreatic mass. There was no evidence of dilatation of the small bowel or colon.

Maximum transverse diameter of the large fusiform aneurysm of the infrarenal aorta is now 7.8 cm. This demonstrates continued growth when compared to the prior MRI. There is a very large mural thrombus noted in association with this aneurysm.

The aneurysm at the level of the aortic hiatus is described on the CT chest report. This aneurysm also contains a large amount of mural thrombus.

There was no evidence of ascites or free fluid within the abdomen. There was no evidence of retroperitoneal hemorrhage at this time.

IMPRESSION:

1. The infrarenal aneurysm of the abdominal aorta has increased in size as described above.




CT Left Shoulder Report #2

PATIENT NAME: Debra Jones
ID NUMBER: 240804
REFERRING PHYSICIAN: Dr.
DATE OF SERVICE: 12/01/10
DOB:

 

NONCONTRAST CT OF THE LEFT SHOULDER:

CLINICAL HISTORY: Left shoulder pain.

TECHNIQUE: Standard noncontrast shoulder technique.

FINDINGS:The obvious structures are intact. There is no dislocation. The infraspinatus and teres minor tendons are maintained. There is a focal vertical tear of the supraspinatus tendon at the insertion, which appears full thickness. There is no tendon retraction. The subscapularis tendon is intact.

The long head of the biceps tendon is in anatomic location and the biceps anchor is maintained. There is no detached labral tear.

The acromioclavicular joint is unremarkable. There is no glenohumeral joint effusion. There is no disproportionate muscle atrophy.

IMPRESSION:

1. Focal vertical/linear full-thickness tear of the supraspinatus tendon laterally at the insertion. No evidence for tendon retraction.




CT Lumbar Spine Report #3

PATIENT NAME: Debra Jones
ID NUMBER: 240804
REFERRING PHYSICIAN: Harry Richard, M.D.
DATE OF SERVICE: 12/01/10
DOB:

 

CT OF THE LUMBAR SPINE:

CLINICAL HISTORY: Low back pain radiating into both legs.

TECHNIQUE: CT was performed of the lumbar spine utilizing standard protocol. Sagittal and coronal reconstructions were utilized for this examination. The current study is compared to an MRI of the lumbar spine performed the same day.

FINDINGS:There are five vertebrae with lumbar configuration. There is a 4.5 x 2.7 cm cystic structure noted on the lowest cut of the examination to the right of midline. This may represent a right adnexal cyst. Correlation with pelvic sonography is recommended.

There is preservation of the normal lumbar lordosis. There is 4-mm retrolisthesis of L2 on L3. 4-mm retrolisthesis of L3 on L4 and 2-mm retrolisthesis of L4 on L5. There is subchondral sclerosis involving the inferior endplates of L2, L3 and L4 and superior endplates of L3 and L4.

There is calcification of the annulus at the L5-S1 level.

At the T12-L1 and L1-L2 levels, no significant abnormality is detected.

At the L2-L3 level, there is moderate loss of height of the disc. There is retrolisthesis of L2 on L3 as described above. A diffuse annular bulge is present. The central canal is diminished in cross-sectional area without evidence of central spinal stenosis. There is no evidence of significant facet spurring or foraminal narrowing.

At the L3-L4 level, there is severe loss of height of the disc. As noted above, there is a prominent retrolisthesis of L3 on L4. There is a mild diffuse annular bulge present. The central canal appears adequate in caliber. There is evidence of bilateral facet hypertrophy with mild foraminal narrowing on the left.

At the L4-L5 level, there is severe loss of height of the disc and a mild retrolisthesis of L4 on L5. A mild diffuse annular bulge is present. There is a droplet of nitrogen gas in the left anterior epidural space indicating the presence of a radial tear of the annulus. However, there is no evidence of focal disc protrusion. The central canal appears adequate in caliber. There is bilateral facet hypertrophy with calcification of the joint capsules bilaterally. There is mild foraminal narrowing on the left.

At the L5-S1 level, disc height is preserved. The posterior margin of the disc appears unremarkable. The central canal is adequate in caliber. There is evidence of bilateral facet spurring without significant foraminal narrowing

IMPRESSION:

1. Diffuse degenerative changes without evidence of focal disc protrusion as described above. The changes are similar to those noted on the MRI. Please see complete discussion above.




CT Sinuses Report #4

RE: Debra Jones
DATE: 12/01/10
MR: 240804
DOB: 12/01/65

 

CT SINUSES WITHOUT CONTRAST:

CLINICAL HISTORY: Sinus infection.

TECHNIQUE: Noncontrast CT of the paranasal sinuses was performed.

FINDINGS:There is slight rightward deviation of the anterior aspect of the nasal septum. The nasal turbinates are within normal limits. There is normal aeration of the paranasal sinuses, without mucosal thickening or opacification. There is no air-fluid level identified. The ostiomeatal units appear patent.

The facial and orbital soft tissue structures are within normal limits. There is no fluid collection or inflammatory stranding.

IMPRESSION:

1. Within normal limits. No sinus inflammatory changes identified.

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