Anastasia Zherlitsyna — timeline

                                                                   MEDICAL DOCUMENTATION
                                                                     Form of primary accounting
                                                                       documentation No. 028/0
  Ministry of Health of Ukraine                                              APPROVED
                                                                    Order of the Ministry of Health
                                                                   of Ukraine of February 14, 2012
 LLC "Medical clinic "Innovation"
     Phone: (044) 331-21-00,
                                                                               No. 110
         (067) 503-59-22
 License of the Ministry of Health
    of Ukraine AB No. 539367




                PROTOCOL COMPUTER TOMOGRAPHY DESCRIPTION

Patient’s name: Zherlitsyna Anastasia Stanislavivna,              Type of research: CT

                46 years old
                                                                  Use of contrast agent: +C
Phone number: 0685975246
Patient's ID: 7140773
Document No. 28689
Outpatient card No. 28689 dated 12.12.2022
Department:      Polyclinic department                      from 01/04/2023 15:40:00

Radiation load: 2737 Total DLP mGy*cm
                                                            Doctor: Shevchenko Volodymyr Serhiiovych



Protocol:

The middle structures are not displaced. The subarachnoid spaces are expanded.
Post-contrast scans did not reveal pathological foci in the substance of the brain and cerebellum. The
ventricles of the brain are not expanded. The craniovertebral region is unremarkable. There are no
pathological changes in the pituitary gland.
Orbits without features. The paranasal sinuses are pneumatized.
Focal infiltrative changes in the lungs were not detected, multiple small thin-walled ones were present
throughout. Mediastinal lymph nodes are not enlarged.
The trachea and main bronchi are permeable.
Pulmonary embolism was not detected.
No free fluid was detected in the pleural cavities and the pericardial cavity.
No CT-visible pathology was detected in the mammary glands.
Supra-, subclavian, axillary lymph nodes are not enlarged.
The craniocaudal size of the liver is 242 mm, bilobular single massive heterogeneous foci with central
zones of reduced density, size S1 15 mm, S2\3 85x65 mm, S8 subcapsular 100x70 mm, S5,6,7
200x130x180 mm almost completely represented by the central cystic component, subcapsular in S8
25x13 mm.
Intrahepatic bile ducts are minimally dilated in the left lobe at S7.8 to 2-4 mm. Portal vein without
thrombosis.
Gallbladder: does not contain radiopaque calculi, common bile duct is not dilated.
The pancreas is displaced to the left by an enlarged liver, the dimensions are typical, the parenchyma
is without focal changes, the duct is not dilated.
Kidneys, pelvicalyceal system, ureters without features, the right kidney is displaced by an enlarged
liver to the level of the wing of the ilium. The concentration and excretory functions are not disturbed.
Adrenal glands without features.
The spleen is not enlarged, the structure is homogeneous.
Lymph nodes of the abdominal cavity, retroperitoneal space, pelvic localization, inguinal are not
enlarged.
Ascites was not detected. Stomach, intestinal loops without CT-visible pathology.
Interloop in the left mesogastric implant 65x50 mm of soft tissue density, closely adjacent to the walls
of the body of the stomach in the lower third and the capsule of the tail of the pancreas.

The body of the uterus is 45x42 mm, the myometrium is heterogeneous, in the area of the bottom, a
heterogeneous formation with tuberous contours up to 75x55 mm protrudes beyond the contours. The
cervix without CT-visible pathology. Ovaries: in the projection of the right, a three-dimensional
formation with clear, even contours, homogeneous, with a density of up to +45 H units, dimensions of
75x45 mm, the left one is structurally unchanged, with dimensions of up to 30x15 mm.
Bladder: the contents are homogeneous, the wall is not thickened.
There are no destructive changes in the bone window, no degenerative changes, no visible areas of
lytic destruction within the limits of the method.




Area research:

The brain, organs of the chest, abdominal cavity and pelvis.




Conclusion:

Leyomiosarcoma of the uterus, condition after 4 cycles of chemotherapy. CT signs of secondary
damage to the liver parenchyma, interloop implant of the left mesogastric, bulky formation in the
projection of the right ovary (implant in the Douglas space?), minimal signs of portal hypertension.
From December 1, 2022, a CT picture without visible dynamics.




Recommendations:

PROVIDE PREVIOUS CT (CD) DISKS AT EACH SUBSEQUENT EXAMINATION!!!




              Radiologist                              _____________________________________
                                                         / Shevchenko Volodymyr Serhiiovych /