CT scan protocol (comparison with 04.01.2023)
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 |
|---|---|
Document No. 28689 Outpatient card No. 28689 dated 12.12.2022 Department: Polyclinic department Equivalent dose: 2737 Total DLP mGy*cm |
from 09.02.2023 14:04:00 Doctor: Shevchenko Volodymyr Serhiiovych |
Use of contrast agent: +C
Comparison with the previous CT from January 4, 2023.
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.
The right jugular access port is unremarkable.
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 right lobe of the liver is 210 mm (previously 242 mm), bilobar solitary massive heterogeneous foci with central zones of reduced density measuring S1 15 mm (previously 15 mm), S2\3 65x45 mm (previously 85x65 mm), S8 subcapsular 90x60 mm (previously 100x70 mm), S5,6,7 184x114x160 mm (previously 200x130x180 mm) is almost completely represented by the central cystic component, subcapsular in S8 without changes (previously 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, choledoch 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.
Adrenal glands without features.
The spleen is not enlarged, the structure is uniform.
Lymph nodes of the abdominal cavity, retroperitoneal space, pelvic localization, inguinal ones are not enlarged.
Ascites was not detected. Stomach, intestinal loops without CT-visible pathology.
Interloop in the left mesogastric implant 55x40 mm (previously 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 without visible dynamics. 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 75x45 mm - without visible dynamics, 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.
Organs of the chest, abdomen and pelvis.
Leiomyosarcoma of the uterus, condition after 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 biliary hypertension. From January 4, 2023, the dynamics are positive - the foci in the liver regressed by 12%, the size of the interloop implant decreased by 15%, otherwise there were no visible dynamics.
PROVIDE PREVIOUS CT (CD) DISKS AT EACH SUBSEQUENT EXAMINATION!!!