CT of the brain after a fall
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, 46 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: 1095 Total DLP mGy*cm |
from 13.02.2023 11:18:00 Doctor: Shevchenko Volodymyr Serhiiovych |
Use of contrast agent: No contrast enhancement
Comparison with MR-examination with intravenous contrast from January 13, 2023 - retrospective analysis.
The middle structures are not displaced. The subarachnoid spaces are expanded.
On native scans, subcortically in the left occipital lobe, there is an area of reduced density up to 17 mm without perifocal edema, otherwise no pathological foci in the substance of the brain and cerebellum were detected (preliminarily according to MRI data - cortical/subcortical in the convexity sections of the parietal-temporal-occipital zone, symmetrically multiple zones of hyperintense MR signal in the T2 mode without convincing signs of diffusion limitation on DWI-sequences, with intravenous contrast weakly intense fixation of the paramagnet, also against this background, in the frontal and occipital zones, small hypointense inclusions conditionally up to 3 mm - hemorrhages, periventricular zones of leukoaraiosis up to 2 mm are symmetrically noted).
Data on hemorrhage were not obtained.
The ventricles of the brain are not expanded.
The craniovertebral region is unremarkable. There are no pathological changes in the pituitary gland area. Orbits without peculiarities.
The paranasal sinuses are pneumatized.
Bone-destructive changes are not determined, soft tissues from the scan zone are without features.
Brain.
An area of reduced density subcortically in the left occipital lobe may correspond to an ischemic zone, as signs of residual phenomena of PRES-encephalopathy. Retrospectively, according to MRI data from January 13, 2023 - MR signs of PRES encephalopathy.
PROVIDE PREVIOUS CT (CD) DISKS AT EACH SUBSEQUENT EXAMINATION!!!