Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Angiography - 1
Description: Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
(Medical Transcription Sample Report)
CT ANGIOGRAPHY CHEST WITH CONTRAST
REASON FOR EXAM: Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.
TECHNIQUE: Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.
FINDINGS: There is no evidence of any acute pulmonary arterial embolism.
The main pulmonary artery is enlarged showing a diameter of 4.7 cm.
Postsurgical changes of a left upper lobectomy are seen. Left lower lobe atelectasis is noted. A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12). A small left pleural effusion is noted.
Right lower lobe atelectasis is present. There is a right pleural effusion, greater than as seen on the left side. A right lower lobe pulmonary nodule measures 1.5 cm. There is a calcified granuloma within the right lower lobe.
1. Negative for pulmonary arterial embolism.
2. Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.
3. Cardiomegaly with mitral valvular calcifications.
5. Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.
6. Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.
Keywords: cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,