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 - 11

Description: Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast.
(Medical Transcription Sample Report)

EXAM: CT pelvis with contrast and ct abdomen with and without contrast.

INDICATIONS: Abnormal liver enzymes and diarrhea.

TECHNIQUE: CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.

COMPARISON: There were no comparison studies.

FINDINGS: The lung bases are clear.

The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.

There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.

There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.

There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.

The urinary bladder is unremarkable. The uterus is not visualized.

IMPRESSION:
1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.
2. Nonspecific retroperitoneal and mesenteric lymph nodes.
3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.
4. Diverticulosis without evidence of diverticulitis.
5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.
6. Osteopenia and degenerative changes of the spine and pelvis.

Keywords: radiology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, 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