CT consultation of the chest, abdomen and pelvis (second translation copy)
Ministry of health of Ukraine
LLC "Medical clinic "Innovation"
Phone: (044) 331-21-00,
(067) 503-59-22
License AE 459319 dated August 27, 2014 issued by the Ministry of Health of Ukraine
Code for the Unified State Register of Enterprises and Organizations of Ukraine 36076865
MEDICAL DOCUMENTATION
Form of primary accounting
documentation No. 028/0
APPROVED
Order of the Ministry of Health
of Ukraine of February 14, 2012
No. 110
PROTOCOL COMPUTER TOMOGRAPHY DESCRIPTION
Patient: Zherlitsyna Anastasia Stanislavivna, 47 y.o. Phone number: 0685975246 Patient's ID: 7140773 |
Insurance Company Policy No. Coordinator |
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Document No. 28689 Outpatient card No. 28689 dated 12.12.2022 Department: Polyclinic department Equivalent dose: |
from 28.07.2023 11:24:00 Doctor: Omelchenko Andrii Yuriyovych |
Use of contrast agent: -
On the presented CT scans from June 28, 2023 – organs of the chest, abdominal cavity, and pelvis with intravenous contrast: Comparison with the CT component of the PET-CT study from April 11, 2023 - only the portal phase of the study is presented.
No focal infiltrative changes were found in the lungs, multiple small thin-walled ones were present throughout. The lymph nodes of the mediastinum are not enlarged.
The trachea and main bronchi are permeable.
No pulmonary embolism (PE) was detected.
Port right jugular access without features.
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 liver craniocaudal size of the right lobe is 200 mm (previously 215 mm), bilobed single massive foci with central zones of cystic density in dynamics with dimensions S1 15 mm (previously 18 mm), S2\3 52x40 mm (previously 72x62 mm), S8 subcapsular 75x50 mm ( previously 102x70 mm), S5,6,7 172x106x150 mm (previously 205x122x172 mm) almost completely represented by the central cystic component, subcapsular in S8 22x10 mm (previously 30x12 mm).
Intrahepatic bile ducts are minimal in the left lobe up to 2 mm. Portal vein without thrombosis.
Gallbladder: does not contain radiopaque calculi, choledoch 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 iliac bone. 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 there is a volume formation of 47x35 mm (previously 62x45 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: the myometrium is heterogeneous, in the area of the bottom, a heterogeneous formation protruding beyond the contours (more data for a myomatous node on the leg) with tuberous contours up to 90x70 mm (previously 70x45 mm) with central zones of reduced density. 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 od H, dimensions of 65x42 mm (previously 65x50 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.
CT consultation (CD)
According to the patient's history: GIST of the stomach with secondary liver damage. CT signs of secondary damage to the liver parenchyma, minimal signs of biliary hypertension. In comparison with the study of April 11, 2023, further regression of foci in the liver is noted - regression to 18% with the appearance of a central cystic component, a decrease in the size of the volume formation between the loops in the left mesogastric region - regression to 28%. A decrease in the size of the volume formation in the projection of the right ovary. The myomatous node on the leg has increased in size.
PROVIDE PREVIOUS CT (CD) DISKS AT EACH SUBSEQUENT EXAMINATION!!!