Radiology Medical Report
Radiology Medical Report
Patient Information
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Patient Name: |
[Your Name] |
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Patient ID: |
123456789 |
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Date of Birth: |
January 1, 2050 |
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Gender: |
Female |
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Contact Information: |
123-456-7890 |
Examination Details
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Type of Study: Computed Tomography (CT) Abdomen and Pelvis
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Indication for Study: The patient presents with acute abdominal pain and clinical suspicion of appendicitis.
Findings
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Abdomen:
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Liver: The liver is within normal limits, showing no focal lesions or signs of hepatomegaly. The echogenicity appears homogeneous.
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Gallbladder: The gallbladder is distended, with a calculi identified in the neck. There are no signs of wall thickening or pericholecystic fluid, indicating no acute cholecystitis at this time.
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Appendix: The appendix is notably enlarged, measuring approximately 7 mm in diameter, with adjacent fat stranding, consistent with acute appendicitis.
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Pelvis:
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Bladder: The urinary bladder is normal in size and contour, without evidence of wall thickening or masses.
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Other Findings: No free fluid or significant mass lesions are observed in the pelvic region. No abnormalities were noted in the reproductive organs.
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Impression
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Primary Diagnosis: Enlarged appendix with surrounding fat stranding, consistent with acute appendicitis.
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Recommendation: Surgical consultation is strongly advised for further evaluation and management of the suspected appendicitis. Consider follow-up imaging if clinical symptoms persist.
Signature:
Dr. Johnson, MD,
Consulting Radiology
