DOB: 01/27/1941
Gender: Male
Age: 76
100 Main Street
Philadelphia, PA 19047
Gender: Male
Age: 76
100 Main Street
Philadelphia, PA 19047
Medication Allergies
Medication 1
Medication 2
Medication 3
Medication 2
Medication 3
Abdominal CT-Scan Date: 1/27/17
Notes
Guidelines
Exam Performed: CT Abd and Pelvis IV Con Only
Exam Date/Time: 1/27/17
Req # 12-3456789
Accession #10987654321SJM
Dictating Dr.: Doug Ross MD
Primary Dr. Enterprise Physician None
Procedure: CT OF THE ABDOMEN AND PELVIS WITH IV CONSTRAST
History: Epigastric Pain
Comparison: None.
Technique: Following the administration of IV contrast, 3mm contiguous helical images were obtained from the lung basis through the ischial tuberosities. Coronal and sagittal reconstructions were performed. 3D reformatting was performed by the radiologist at an independent workstation.
This patient received a total of 1 exposure event(s) during this CT examination. The CTDivol and DLP radiation doses values for each exposure are:
Exposure 1; Series 2, Anatomy Abdomen, Phantom 32cm, CTDivol (mGy), 13, DLP (mGy-cm) 605
Findings: Lung bases show no pleural or pericardial effusions. There is a small hiatal hernia present.
The liver has mildly decreased density consistent with fatty infiltration. The gallbladder, pancreas, adrenal glands, and kidneys show no abnormalities. The spleen is upper limits of normal size, measuring 11.9x 7.0cm. There is no intra-abdominal or pelvic lymphadenopathy
The uterus and ovaries show no abnormalities.
Evaluation of the loops of bowel is limited without oral contrast as ordered. There is mural thickening of the ascending, transverse, and parts of the descending colon with mild surrounding inflammatory stranding. There is no abscess. A normal appearing noninflamed appendix is identified within the low right quadrant (image 99, series 2). Small bowel loops show no abnormalities.
Bone window show no suspicious appearing osseous lesions
IMPRESSION:
1. There is a 7 mm distal left ureteral calculus located 10 mm from the left ureterovesical junction, associated with moderate to sever left hydronephrosis and hydroureter.
2. The left kidney is enlarged with surrounding inflammatory stranding suggesting secondary pyelonephritis.
Results discussed with Dr. Young on 1/27/17 7:51 PM
Exam Date/Time: 1/27/17
Req # 12-3456789
Accession #10987654321SJM
Dictating Dr.: Doug Ross MD
Primary Dr. Enterprise Physician None
Procedure: CT OF THE ABDOMEN AND PELVIS WITH IV CONSTRAST
History: Epigastric Pain
Comparison: None.
Technique: Following the administration of IV contrast, 3mm contiguous helical images were obtained from the lung basis through the ischial tuberosities. Coronal and sagittal reconstructions were performed. 3D reformatting was performed by the radiologist at an independent workstation.
This patient received a total of 1 exposure event(s) during this CT examination. The CTDivol and DLP radiation doses values for each exposure are:
Exposure 1; Series 2, Anatomy Abdomen, Phantom 32cm, CTDivol (mGy), 13, DLP (mGy-cm) 605
Findings: Lung bases show no pleural or pericardial effusions. There is a small hiatal hernia present.
The liver has mildly decreased density consistent with fatty infiltration. The gallbladder, pancreas, adrenal glands, and kidneys show no abnormalities. The spleen is upper limits of normal size, measuring 11.9x 7.0cm. There is no intra-abdominal or pelvic lymphadenopathy
The uterus and ovaries show no abnormalities.
Evaluation of the loops of bowel is limited without oral contrast as ordered. There is mural thickening of the ascending, transverse, and parts of the descending colon with mild surrounding inflammatory stranding. There is no abscess. A normal appearing noninflamed appendix is identified within the low right quadrant (image 99, series 2). Small bowel loops show no abnormalities.
Bone window show no suspicious appearing osseous lesions
IMPRESSION:
1. There is a 7 mm distal left ureteral calculus located 10 mm from the left ureterovesical junction, associated with moderate to sever left hydronephrosis and hydroureter.
2. The left kidney is enlarged with surrounding inflammatory stranding suggesting secondary pyelonephritis.
Results discussed with Dr. Young on 1/27/17 7:51 PM
