Radiology Medical Report
Patient Information
Patient Name: | [Your Name] |
Patient ID: | 123456789 |
Date of Birth: | January 1, 2050 |
Gender: | Female |
Contact Information: | 123-456-7890 |
Examination Details
Findings
Abdomen:
Liver: The liver is within normal limits, showing no focal lesions or signs of hepatomegaly. The echogenicity appears homogeneous.
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.
Appendix: The appendix is notably enlarged, measuring approximately 7 mm in diameter, with adjacent fat stranding, consistent with acute appendicitis.
Pelvis:
Bladder: The urinary bladder is normal in size and contour, without evidence of wall thickening or masses.
Other Findings: No free fluid or significant mass lesions are observed in the pelvic region. No abnormalities were noted in the reproductive organs.
Impression
Primary Diagnosis: Enlarged appendix with surrounding fat stranding, consistent with acute appendicitis.
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
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