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.
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.
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: nephrology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct,