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 - 10

Description: Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.
(Medical Transcription Sample Report)

CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST

REASON FOR EXAM: Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.

CT ABDOMEN: There is no evidence for a retroperitoneal hematoma.

The liver, spleen, adrenal glands, and pancreas are unremarkable. Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion. A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney. No calcifications are noted. The kidneys are small bilaterally.

CT PELVIS: Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended. The large and small bowels are normal in course and caliber. There is no obstruction.

Bibasilar pleural effusions are noted.

IMPRESSION:
1. No evidence for retroperitoneal bleed.
2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.
3. The kidneys are small in size bilaterally.
4. Bibasilar pleural effusions.

Keywords: nephrology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, 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