CT Abdomen Report Sample:

Start your career and take advantage of the new student offers.

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.