Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis - 2

Description: CT scan of the abdomen and pelvis without and with intravenous contrast.
(Medical Transcription Sample Report)

EXAM: CT scan of the abdomen and pelvis without and with intravenous contrast.

CLINICAL INDICATION: Left lower quadrant abdominal pain.

COMPARISON: None.

FINDINGS: CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered.

The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses.

There is no intra or extrahepatic ductal dilatation.

The gallbladder is slightly distended.

The adrenal glands, pancreas, spleen, and left kidney are normal.

A 12-mm simple cyst is present in the inferior pole of the right kidney. There is no hydronephrosis or hydroureter.

The appendix is normal.

There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection.

The aorta is normal in contour and caliber.

There is no adenopathy.

Degenerative changes are present in the lumbar spine.

IMPRESSION: Findings consistent with diverticulitis. Please see report above.

Keywords: nephrology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples