CT scan of the abdomen and pelvis
Ministry of Health of Ukraine
DOCTOR FILIN LLC
Ukraine, Kyiv, K. Malevicha str, 86-G; pr t.L. Huzara, 3, k-5., Vidpochynku str, 11
phone: 237-13-43, 095-5576633, 098-5576633
License of the Ministry of Health of Ukraine AB No. 539367
MEDICAL DOCUMENTATION
Primary accounting form
documentation No. 028/0
APPROVED
Order of the Ministry of Health of Ukraine
14.02.12 No. 110
COMPUTER TOMOGRAPHY DESCRIPTION PROTOCOL
Name of the survey:
CT scan of the chest cavity, abdominal cavity organs with retroperitoneal space and pelvic organs before and with contrast
Contrast agent Omnipak 350 mg of iodine/ml. volume 100 ml. Radiation load 2163 mGy* cm.sq
There was no reaction to the contrast agent
The patient's name is Zherlitsyna Anastasia Stanislavivna, the patient's ID is 74595
Date of birth 25.04.1976 Examination date 23.08.2022
The name of the CT operator who performed the examination is Gerashchenko Oksana Vasylivna
Protocol:
Cervical, supraclavicular and subclavian lymph nodes are not enlarged.
Axillary lymph nodes are not enlarged.
The thyroid gland is not enlarged, homogeneously accumulates contrast.
Lungs are uniformly pneumatized, no infiltrative areas were found, few small nodules up to 3 mm. The vascular pattern is evenly distributed. The trachea and main, partial and segmental bronchi are permeable. No free fluid was found in the pleural cavities.
The heart is not enlarged, the cavities are evenly contrasted. Free fluid is not visualized in the pericardium. Ascending and descending aorta, cephalic trunks without changes. Pulmonary arteries, superior vena cava and inferior vena cava are not dilated, no changes. Intrathoracic lymph nodes are not enlarged. The esophagus is not dilated, its walls are not thickened. Aperture without features.
No free fluid was detected in the abdominal cavity. Cardia, stomach, duodenum, small and large intestine are not dilated, without reliable lesions.
The liver is enlarged, the craniocaudal size of the liver is 198 mm, single formations of heterogeneous structure with necrosis in the center are visualized bilobed, vascularization is pronounced on the periphery. Partial hepatic veins, left portal vein unchanged, right portal vein not visualized. Intrahepatic bile ducts: local dilatation in Sg3, not dilated in other interspaces of the liver. In the hepatoduodenal ligament: the portal vein is not dilated. Choledochus is not dilated. Gallbladder is not visualized.
The pancreas is compressed, the parenchyma contrasts uniformly. The duct of the gland is not dilated. Above the tail of the gland, a nodular formation of heterogeneous density is visualized, with pronounced vascularization on the periphery (neoangiogenesis), size 51x46mm (more likely it is not connected with the pancreas, it compresses it from the outside. It is closely adjacent to the stomach, loops of the jejunum).
The spleen is not enlarged, the structure is homogeneous. The splenic vein is not dilated. The lymph nodes of the portal of the spleen are not enlarged.
The adrenal glands are symmetrical and not enlarged.
Kidneys: the right is displaced downward by an enlarged liver, the left is located in a typical place. The parenchyma of both kidneys is not thinned. Cortico-medullary differentiation is not disturbed. Pelvicalyceal system, ureters are not expanded. There are no calculi in the renal pelvis and ureters. The excretory function is not disturbed. The trunk vessels of the retroperitoneal space are unchanged. Lymph nodes of the retroperitoneal space: few para-aortic up to 8 mm.
Urinary bladder - the walls are not thickened, internally there are no luminal formations.
In the small pelvis: above the urinary bladder, in front of the bottom of the uterus - a nodular heterogeneous formation, with pronounced vascularization (neoangiogenesis), with single small calcifications, size 93x63 mm, with necrosis, it is difficult to exclude or confirm the connection with the uterus; above and to the right of the uterus - a rounded formation of 67x57 mm, without obvious accumulation of contrast (hemorrhagic cyst of the right ovary?).
The uterus is not enlarged, on the right surface of the body there is a 37×27 m node (probably a subserous myoma). Ovaries - differentiation is difficult. A small amount of fluid in the pelvis.
The lymph nodes of the abdominal cavity, pelvis, and groin are not enlarged.
In bones there are no osteolytic, sclerotic foci.
CONCLUSION:
Single neoplasms in the pelvis, in the abdominal cavity above the tail of the pancreas (to be differentiated from Gist). Metastases in the liver, bilobed.
Single small nodules in the lungs - observation in dynamics.
Uterine myoma, hemorrhagic cyst? of the right ovary.
Recommendations:
Consultation of an oncologist. According to clinical need - MRI of the abdominal cavity, pelvis. Histological verification.
23.08.2022