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Impressions, summaries, and differential diagnosis
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WillyAI adapts to different imaging modalities and report types, automatically formatting your dictation into your custom structured reports.
Multiphasic upper abdominal CT. Reason for referral: Upper abdominal pain. The liver is enlarged with diffuse fatty infiltration in segment 4 there is an early enhancing lesion measuring up to 21 mm, wait, change it to 28 mm with washout during the venous phase. The finding could be possibly consistent. with HCC. Further evaluation with MRI is advised. Cystic lesion in the upper pole of the left kidney measuring 36 millimeters exhibiting thin septations up to 2 mm without evidence of enhancement. Consistent with Bosniak IIF. Follow-up is advised. In summary also give differential diagnosis
CT Abdomen Multiphasic Protocol focused on Upper Abdomen Technique: Examination performed without and with IV contrast administration and oral contrast. Arterial and venous phase scans were obtained. Reason for referral: Upper abdominal pain Comparison with previous examination: No relevant previous examinations available for comparison. Findings: Chest/abdomen junction: No abnormal findings. Liver: Enlarged with diffuse fatty infiltration. A 28 mm lesion is noted in segment 4 showing early arterial enhancement with washout in the venous phase, findings possibly consistent with HCC. No evidence of intra or extrahepatic biliary dilatation. Gallbladder is normal in size, without calcified stones. Pancreas is normal in size, without solid or cystic lesions. No pathological dilatation of the pancreatic duct. Spleen is normal in size, without focal lesions. Both adrenal glands show no masses. Left kidney shows a 36 mm cystic lesion in the upper pole with thin septations up to 2 mm, without enhancement, consistent with Bosniak IIF classification. Right kidney is normal in length with preserved parenchymal thickness. No evidence of stones in the collecting systems of both kidneys, no signs of mechanical obstruction. Abdominal aorta is of normal caliber. No evidence of mesenteric or retroperitoneal lymphadenopathy. Bowel loops show no abnormal findings. Pelvic organs show no abnormal findings. Bone window: No abnormal findings. Summary: - Liver segment 4 lesion (28 mm) with arterial enhancement and venous washout - differential diagnosis includes HCC, other hypervascular lesions such as FNH, adenoma. MRI recommended for further characterization - Hepatomegaly with diffuse fatty infiltration - Left kidney Bosniak IIF cystic lesion (36 mm) requiring follow-up
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CT CHEST WITHOUT CONTRAST
Patient ID: 12345678
TECHNIQUE:
Examination performed without contrast media administration.
REASON FOR REFERRAL:
No reason provided.
COMPARISON:
No relevant previous examinations available for comparison.
FINDINGS:
Thyroid gland lobes within scanning range appear unremarkable. Superior mediastinum is unremarkable. Thoracic aorta is of normal caliber. Pulmonary arteries are not dilated. Heart is normal in size, no pericardial effusion. No pleural effusion demonstrated. No evidence of thoracic or axillary lymphadenopathy.
Lung parenchyma:
Normal volume of both lungs. No evidence of alveolar or interstitial infiltrates. No pulmonary nodules or masses. Airways are unremarkable.
Upper abdomen:
Adrenal glands show no masses. Liver, spleen, and pancreas appear unremarkable (as far as can be evaluated within the limitations of the scanning protocol).
Bone window:
No abnormality demonstrated.
SUMMARY:
- No significant pulmonary findings.
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Dr. Pedro Alves
Musculoskeletal Radiologist
Specialty
Musculoskeletal
Impact
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