Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - 1

Description: CT Abdomen and Pelvis with contrast
(Medical Transcription Sample Report)

EXAM: CT Abdomen and Pelvis with contrast

REASON FOR EXAM: Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day.

COMPARISON: None.

TECHNIQUE: CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement.

CT ABDOMEN: Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy.

CT PELVIS: The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT, the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.

IMPRESSION:
1. Unremarkable exam; specifically no evidence for acute appendicitis.
2. No acute nephro-/ureterolithiasis.
3. No secondary evidence for acute cholecystitis.

Results were communicated to the ER at the time of dictation.

Keywords: radiology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct,
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