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 - 9

Description: Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.
(Medical Transcription Sample Report)

CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST

REASON FOR EXAM: Generalized abdominal pain with swelling at the site of the ileostomy.

TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

CT ABDOMEN: The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. Punctate calcifications in the gallbladder lumen likely represent a gallstone.

CT PELVIS: Postsurgical changes of a left lower quadrant ileostomy are again seen. There is no evidence for an obstruction. A partial colectomy and diverting ileostomy is seen within the right lower quadrant. The previously seen 3.4 cm subcutaneous fluid collection has resolved. Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed. This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded. No obstruction is seen. The appendix is not clearly visualized. The urinary bladder is unremarkable.

IMPRESSION:
1. Resolution of the previously seen subcutaneous fluid collection.
2. Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance. These findings may be due to a pelvic abscess.
3. Right lower quadrant ileostomy has not significantly changed.
4. Cholelithiasis.

Keywords: nephrology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,
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