COMPARISON EXAM:
CLINICAL HISTORY:
TECHNIQUE:
FINDINGS:
IMPRESSION:
PA & LATERAL CHEST:
The cardiomediastinal silhouette is normal. The lungs are clear bilaterally. No pleural effusions, consolidations or evidence of congestive heart failure. The visualized osseous structures are unremarkable.
Diffuse air-space opacities | "Diffuse, confluent opacities with ill-defined borders ..."
" ... in a perihilar (or lobar, segmental, etc.) distribution ..." " ... interspersed with small lucencies / air alveolograms / air bronchograms ..." " ... surrounded by acinar rossetes (opacities) ..." | Blood
Pus - e.g. bronchopneumonia, mycoplasma, viral, PCP Fluid - e.g. pulmonary edema (cardiogenic, non-cardiogenic) Cells - e.g. mets, lymphoma Protein - e.g. PAP |
Multi-focal ill-defined opacities | "Multi-focal ill-defined opacities ..." (or "Patchy alveolar pattern ...") | Vasc: emboli (thromboembolic, septic), vasculitis (e.g. Wegener's)
Inf: e.g. bronchopneumonia, TB, fungal, PCP Iatro: drugs, radiation Neoplasia: e.g. mets, lymphoma, bronchioloalv cell Ca |
Airspace consolidations in adults must be followed to complete imaging resolution.
ACUTE ABDOMINAL SERIES:
The PA view of the chest demonstrates a normal cardiomediastinal silhouette. The lungs are clear bilaterally. No pleural effusions, consolidations or free air beneath the diaphragm.
The upright and supine view of the abdomen demonstrate a normal bowel gas pattern. There is no evidence of bowel obstruction or abnormal calcifications. The visualized bony skeleton is unremarkable.
FINDINGS: VP shunt begins in left lateral ventricle and exits cranium through right frontal craniotomy. It then travels down the subcutaneous tissues of the right side of the head, chest and abdomen and loops in the peritoneal cavity and finally terminates in the lower peritoneal cavity in the midline.
The VP shunt is intact. No discontinuity, obstruction, or kinking.
The visualized osseous structures and other structures including lungs and bowel gas pattern is within normal limits.
IMPRESSION: VP shunt intact and patent.
GENERAL MSK:
No fractures, subluxations, abnormal calcifications, radio-opaque foreign bodies, effusions, or soft tissue swelling.
FIVE VIEWS OF THE CERVICAL SPINE:
The spinal alignment, vertebral body heights and disk spaces are within normal limits. There is no evidence of acute fracture or dislocation. There is no prevertebral soft tissue swelling. The distance between the odontoid process and anterior arch is within normal limits. The neural foramina are patent bilaterally.
THREE VIEWS OF THE LUMBOSACRAL SPINE:
There are five lumbar type vertebral bodies. The spinal alignment, vertebral body heights and disk spaces are within normal limits. No acute fracture or spondylolisthesis. The sacroiliac joints are intact bilaterally.
Discogenic vertebral sclerosis involving the superior aspect of L4 and inferior aspect of L3.
FOUR VIEWS OF THE KNEE:
"Findings compatible with prior ACL repair."
"Limited views of left knee do not reveal any gross abnormalities."
FOUR VIEWS OF THE ANKLE:
There is no evidence of acute fracture or dislocation. No significant soft tissue swelling, joint effusion, abnormal calcifications or radio-opaque foreign bodies. The base of the fifth and ankle mortise is intact.
Possible pes panus deformity, though the lateral view is non-weight bearing, thus this cannot be confirmed with certainty.
Recommend MRI if concern about osteomyelitis.
There is an ill-defined, moth-eaten lesion in the upper right humerus with a pathological fracture running transversely through it. There is periosteal reaction with Codman’s triangles on the superior part of the lesion.
Imp: Aggressive neoplasm in proximal humerus. Pathological fracture in same location. Most likely etiology is metastatic disease. Also should consider a primary neoplasm. Consider MRI for further characterization, and bone scan to assess for additional lesions.
Degenerative joint disease is present in the right acromioclavicular joint. There are also findings suggestive of rotator cuff disease on the greater tuberosity of the humerus.
The third digit of the right hand demonstrates diffuse soft-tissue swelling, predominately along the proximal interphalangeal joint. There is diffuse DIP and PIP joint degenerative joint disease. The DIP joint in the third digit demonstrates changes that are likely related to osteophytes. No erosion is present. No evidence of osteomyelitis. There is severe DJD in the first carpometacarpal joint.
IMP: Changes in DIP in third digit likely related to osteophytes. There is diffuse degenerative joint disease in the DIP and PIP joints. No evidence of septic arthritis, osteomyelitis, or gout. If concerned about gout, can correlate with serum uric acid level.
CT HEAD:
FINDINGS: The ventricular and cisternal spaces are normal in size, shape and configuration for a patient of this age. No dominant mass, midline shift or hydrocephalus. No intracranial hemorrhage or extra axial fluid collections. No abnormal areas of increased or decreased attenuation within the brain parenchyma. (If the examination was performed with contrast: There are no abnormal areas of contrast enhancement.)
The visualized skull is intact. The intraorbital contents are within normal limits. The visualized paranasal sinuses and mastoid air cells are clear.
IMPRESSION: Normal (enhanced) or (unenhanced) CT scan of the head.
The basilar cisterns are intact.
Evidence of an old infarction in the left MCA territory with ex vacuo dilatation of the adjacent lateral ventricle.
There is an area of decreased attenuation within the left frontal region superior to the sylvian fissure. This may represent an area of new edema or ischemia.
centrum semiovale
concha bullosa
Haller cell
resection of uncinate process and maxillary antrectomy
********************
There is acute blood in the suprasellar cistern and adjacent cisterns and in the sylvian fissures consistent with a subarachnoid hemorrhage. The temporal horns of the lateral ventricles are mildly dilated suggesting early hydrocephalus. The ambient cisterns and adjacent cisterns are not well visualized, which is suggestive of brain parenchymal swelling.
No dominant mass or midline shift. Differentiation between gray matter and white matter is still maintained.
vasogenic edema or glial infiltration or gliosis in right parietal region.
There is a hyperattenuating 8.7 mm lesion in the right posterior parietal area (image #24). This could represent a small hemorrhage versus tumor nodule.
TECHNIQUE: Contiguous axial images using 2 mm collimation from aortic arch to orbits following intravenous administration of contrast. Coronal and sagittal reconstructions done.
FINDINGS: Stable low-density lesion in right lobe of thyroid gland measuring 0.8 cm, likely representing nodule, cyst or adenoma.
Visualized upper lungs are clear. Visualized heart and mediastinum are unremarkable.
Intra-orbital contents within normal limits. Visualized osseous structures and visualized intracranial structures unremarkable. Paranasal sinuses, mastoid air cells and middle ears clear. No asymmetry in pharynx.
CHEST CT WITH (OR WITHOUT) CONTRAST:
FINDINGS: There is no axillary, mediastinal, or hilar lymphadenopathy. The heart and great vessels are within normal limits.
The lungs are clear bilaterally. No pulmonary nodules, infiltrates, or pleural effusions.
The visualized upper abdominal structures are within normal limits.
No sclerotic or lytic lesions are identified within the visualized osseous structures.
CT OF THE ABDOMEN WTH CONTRAST:
FINDINGS: The visualized lung bases are clear. The visualized heart and posterior mediastinal structures are within normal limits.
Intra-abdominally, the liver, gallbladder, pancreas, spleen and adrenal glands are within normal limits. There is no retroperitoneal or mesenteric lymphadenopathy. The visualized loops of small bowel and large bowel are within normal limits. No free fluid or free air within the visualized abdomen.
CT OF THE ABDOMEN & PELVIS WITH CONTRAST:
FINDINGS: The visualized lung bases are clear. The visualized heart and posterior mediastinal structures are within normal limits.
Intra-abdominally, the liver, gallbladder, pancreas, spleen, kidneys, and adrenal glands are within normal limits. No retroperitoneal or mesenteric lymphadenopathy. The visualized loops of small and large bowel are unremarkable. No free air or free fluid within the abdomen or pelvis.
Within the pelvis, the bladder, uterus (or prostate and seminal vesicles) and rectum appear within normal limits. No pelvic lymphadenopathy.
Visualized osseous structures unremarkable. No sclerotic or lytic lesions identified.
CT for Appendicitis
TECHNIQUE: Contiguous axial images from dome of diaphragm to ischial tuberosities using 5 mm collimation after intravenous and oal administration of contrast. 2 mm axial reconstructions performed through the right lower quadrant. 2 mm coronal reconstructions performed through the abdomen and pelvis. Delayed images of the pelvis also obtained with 2D reformats.
FINDINGS: Retrocecal appendix noted in the right lower quadrant; 9 mm in diameter, fluid-filled, and the wall enhances with contrast. No appendicolith is seen. No periappendiceal abscess or fluid collections. No gas within lumen of appendix. Delayed images show well opacified cecum and ascending colon but no contrast or air in the appendix.
IMPRESSION: Findings are suspicious for early appendicitis.
Equivocal for acute appendicitis. Recommend delayed images when contrast has entered the cecum.
BIPHASIC ESOPHAGRAM:
FINDINGS: The caliber, mucosal pattern, and peristalsis of the esophagus are normal. No ulcerations, filling defects, or strictures. No hiatal hernia or gastroesophageal reflux.
MODIFIED BARIUM SWALLOW WITH SPEECH THERAPY:
FINDINGS:
Oral phase: Mastication. Bolus formation.
Premature spill over. Aspiration before swallow.
Pharyngeal phase: Laryngeal elevation. Epiglottic excursion.
Vallecullar / pyriform residue.
Penetration. Aspiration. Cough response.
Esophageal phase: Stricture. Diverticulum. TE fistula.
IMPRESSION: Moderate oral and pharyngeal dysfunction. See Speech Pathology report for recommendations.
BIPHASIC UPPER GI:
FINDINGS: The peristalsis, mucosal pattern and caliber of the esophagus are normal. No hiatal hernia or gastroesophageal reflux.
The caliber and mucosal pattern of the stomach is normal. No ulcers or filling defects.
The proximal duodenum is normal. No ulcers or filling defects.
SMALL BOWEL FOLLOW THROUGH:
FINDINGS: The scout film of the abdomen demonstrates a normal bowel gas pattern. No abnormal calcifications or evidence of bowel obstruction.
The transit time of the barium from the stomach to the cecum was approximately . The peristalsis, mucosal pattern, caliber, and orientation of the duodenum, jejunum and ileum are normal. No strictures, filling defects, ulcers or fistulas. Spot films of the terminal ileum demonstrate no abnormality.
TECHNIQUE: A scout film of the abdomen was obtained. The barium enema tip was inserted into the rectum by the technologist and the balloon inflated by the radiologist under fluoroscopy. Barium was then administered and flowed freely to the cecum. While the barium flowed in, spot films of the colon were obtained intermittently. This was then followed by overhead films of the abdomen in various projections.
FINDINGS: The scout film of the abdomen demonstrates a normal bowel gas pattern. No evidence of bowel obstruction. No abnormal calcifications.
The barium flowed freely to the cecum without reflux into the terminal ileum. There are innumerable diverticula in the sigmoid and descending colon. No evidence of diverticulitis. No evidence of perforation or abscess. Otherwise, the caliber and haustral pattern of the colon is within normal limits. No obvious polyps or masses are seen. No strictures, filling defects, or ulcerations. Spot films of the cecum demonstrate a competent ileocecal valve.
IMPRESSION:
1. Severe diverticulosis without evidence of diverticulitis or other abnormalities. Note that single contrast barium enema is insensitive at detecting mucosal abnormalities. If this is a concern, a double contrast barium enema is recommended.
DOUBLE CONTRAST BARIUM ENEMA:
FINDINGS: The scout film of the abdomen demonstrates a normal bowel gas pattern. No abnormal calcifications or evidence of bowel obstruction.
The barium flowed freely to the cecum with reflux into the terminal ileum. The caliber, haustral pattern and mucosal pattern of the colon is within normal limits. No pulps or masses. No strictures, filling defects or ulcerations. Spot views of the cecum demonstrate a normal ileocecal valve.
ERCP:
FINDINGS: Spot films are presented for interpretation. There is good filling of the intra and extra hepatic bile ducts. The bile ducts are of normal caliber. No areas of narrowing or filling defects are identified. (filling of the cystic duct and gallbladder. The gallbladder is grossly normal.)
The pancreatic duct was well filled from the head to the tail. This is of normal caliber. No filling defects, mass effect or narrowing.
INTRAVENOUS UROGRAM:
FINDINGS: The scout film of the abdomen demonstrates a normal bowel gas pattern. No abnormal calcifications or evidence of bowel obstruction.
The 30-second nephrogram demonstrates bilaterally symmetric nephrograms. The kidneys are normal in size, orientation, and enhancement. Serial delayed images demonstrate a non-dilated pelvicaliceal system and ureters bilaterally. No obstruction, calculi or filling defects are identified. The course of the ureters is normal. The bladder is well distended and the bladder wall is within normal limits. The post-void image demonstrates no significant post void residual.
CLINICAL HISTORY: 72-year-old male post-op prostatectomy for prostate cancer.
TECHNIQUE: Scout film of the pelvis was obtained. Approximately 150 ml of water soluble contrast was injected into the bladder via an indwelling catheter. Images in various projections were obtained. The bladder was then drained and a post-drainage image was obtained.
FINDINGS: Small contained leak at the base of the bladder on the right side. Miniscule amount of post-drainage residual urine. Minimal bladder trabeculae.
TECHNIQUE: A straight catheter was inserted into the distal urethra and water-soluble contrast was injected into it. Multiple spot films were then obtained in an oblique projection.
HYSTEROSALPINGOGRAM:
TECHNIQUE: The cervical os was cannulated by Dr. of the OB/Gyn Service. Water/soluble contrast was then administered and spot films of the pelvis were obtained.
FINDINGS: No mass lesions are identified in the endometrial canal. The walls of the uterus are smooth. Contrast material flows freely through the fallopian tubes and free spill into the peritoneal cavity is noted bilaterally.
IMPRESSION: Normal patent fallopian tubes bilaterally.
RIGHT UPPER QUADRANT ULTRASOUND:
Multiple axial and sagittal images of the right upper quadrant were obtained.
FINDINGS:
The visualized portions of the pancreas are within normal limits.
The visualized portions of the liver are also within normal limits. No focal lesions or intrahepatic bowel duct dilatation. The common bile duct is within normal limits in size measuring mms. The gallbladder is within normal limits. There is no gallbladder wall thickening, pericholecystic fluid or gallstones.
The visualized portions of the right kidney are within normal limits. No hydronephrosis.
KIDNEYS:
TECHNIQUE: Multiple sonographic images of the kidneys were obtained bilaterally and the axial and longitudinal planes.
FINDINGS: The kidneys are normal in size measuring approximately cms on the right and cms on the left in greatest longitudinal dimension. There is no hydronephrosis, abnormal calcifications, focal masses or perinephric fluid collections involving either kidney. The visualized portions of the bladder demonstrate no abnormalities.
SCROTAL ULTRASOUND:
FINDINGS: The right testicle was normal in size measuring approximately x x cms. The echogenicity of the right testicle was homogeneous. No focal lesions or abnormal calcifications are identified. Blood flow to the testicle is within normal limits. The epididymis is also within normal limits.
The left testicle is normal in size measuring approximately x x cms. The echogenicity of the testicle is homogeneous. No focal lesions or abnormal calcifications are identified within the testicle. Blood flow to the testicle is normal. The epididymis is also within normal limits.
NEONATAL HEAD ULTRASOUND:
FINDINGS: The ventricular system is normal in size bilaterally. There is no evidence of intracranial hemorrhage, mass effect or midline shift. No hydrocephalus. No anomalies are identified.
FLUOROSCOPICALLY GUIDED LUMBAR PUNCTURE (11/16/06):
CLINICAL HISTORY: 33-year-old female with history of pseudotumor cerebri. Status post lumboperitoneal shunt. Recently has been having recurrent headaches.
PHYSICIANS: Dr. K. Evans, Dr. E. Bourekas.
TECHNIQUE: The procedure and its associated risks were explained to the patient and informed consent was obtained.
The patient was positioned on the fluoroscopy table in the prone position. Using fluoroscopy, a suitable path for the lumbar puncture needle was determined. The skin was marked with a felt pen. The skin was then prepped and draped in the usual sterile fashion. The skin and underlying tissues were infiltrated with a total of 8 ml of lidocaine 1% without epinephrine.
Under fluoroscopic guidance, a 20-gauge lumbar puncture needle was inserted through the skin and into the lumbar cistern at the L3 level. Correct placement of the needle was confirmed by return of clear cerebrospinal fluid.
Opening pressure was determined, then 4 ml of cerebrospinal fluid was collected for analysis, then closing pressure was determined.
The stylet was re-inserted into the lumbar puncture needle and the needle withdrawn. Pressure was applied to the lumbar puncture site for 30 seconds. A Band-Aid was then applied to the site.
The patient was able to ambulate immediately. She tolerated the procedure well and there were no complications.
FINDINGS:
Opening pressure: 13 cm of water.
Closing pressure: 7 cm of water.
Amount of CSF removed: 4 ml - taken to the lab for cell count, and glucose and protein determination.
COMPLICATIONS: None.
IMPRESSION: Fluoroscopically guided lumbar puncture without complications.
I personally supervised the performance of this procedure and reviewed and approved the report.
LUMBAR MYELOGRAM
FINDINGS: Minor impression on the thecal sac is noted at L5-S1, which may be related to a small disk osteophyte complex or a small protrusion. This will be further evaluated on the post-myelogram CT. The patient’s known sacral cyst does not demonstrate any opacification with contrast. The remainder of the exam is normal. There is no spinal stenosis. No obvious disk herniation is identified.
POST-MYELOGRAM CT OF THE LUMBAR SPINE
TECHNIQUE: Immediately following the myelogram, serial axial sections were obtained through the lumbosacral spine followed by sagittal and coronal reconstructions.
FINDINGS: At L5-S1, there is evidence of some osteophytic spurring off the posterior superior aspect of the S1 segment primarily centrally and on the left. There appears to be an associated small disk extrusion centrally, which causes minimal flattening of the thecal sac, however no spinal stenosis noted.
At L4-5, there is a minimal bulge of the annulus with no spinal or foraminal stenosis. The remainder of the examination is normal other than some minor degenerative changes of the L5-S1 facets.
ULTRASOUND-GUIDED LIVER BIOPSY:
PHYSICIANS:
TECHNIQUE:
FINDINGS:
Three 18 gauge core biopsy specimens taken to lab in formalin
COMPLICATIONS: None.
IMPRESSION: Ultrasound-guided liver biopsy without complications.
I personally supervised the performance of this procedure and reviewed and approved the report.
TECHNIQUE: The procedure and associated risks were explained to the patient and informed consent was obtained.
The patient as positioned on the CT table in supine position and images were obtained in the subhepatic region. A suitable path for the drainage catheter was determined. The skin was marked with a felt pen. The skin was prepped and draped in the usual sterile fashion. The skin and underlying tissues were infiltrated with total of 5 cc of 1% lidocaine without Epinephrine.
The skin fascia was pierced with an 11 blade scalpel. A trocar needle was inserted down to the abscess. There was return of serosanguinous fluid. Correct positioning of the needle was confirmed by rescanning the patient. The needle trocar was removed and a guidewire inserted through the needle into the abscess. The needle was then withdrawn with the guidewire remaining in the abscess. Then dilators were inserted over the guidewire to dilate the tract for the drainage catheter. A 10 French pigtail catheter was inserted over the guidewire into the abscess. Correct positioning of the catheter was confirmed by return of fluid and by rescanning the patient. The end of the catheter was made into the curled up configuration so that it could not be pulled out. The other end of the catheter was secured to the patient's skin with an adhesive device. The catheter was then connected to a drainage bag. A specimen of the abscess fluid was sent to the lab for culture and sensitivity. A total of approximately 50 cc of fluid was drained during the procedure.
The entire site was then covered by a sterile op-site dressing and the patient was transported back to the ward in stable condition. Patient tolerated the procedure well. No complications.
IMPRESSION: CT-guided placement of drainage catheter in subhepatic abscess without complications.
I personally supervised the performance of this procedure and reviewed and approved the report.