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Audit Report 3.5 CT scan, chest, abdomen, and pelvis LOCATION: Outpatient, Hospital PATIENT: Amy Larson PHYSICIAN: Gregory Dawson, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: CT of chest, abdomen, and pelvis CLINICAL SYMPTOMS: Shortness of breath, nodule of lung, and level 1 trauma due to motor vehicle collision. CT OF CHEST, ABDOMEN AND PELVIS: Technique: CT of the chest, abdomen, and pelvis was performed with oral and IV contrast material. No previous CTs for comparison. FINDINGS: Chest: Small lymph nodes are noted within both axillae, but none are pathologically sized. However, there is lymphadenopathy within the mediastinum with nodes seen within the pretracheal, precarinal, paratracheal, and prevascular regions. The largest node is seen in the right paratracheal region and has a diameter of approximately 1.3 cm in short axis diameter. There are other nodules of approximately 1 cm in size. Bilateral pleural effusions are noted with presumed compressive atelectasis. There is some opacification in the left hilar region with air bronchograms seen within it, which could be due to atelectasis, although other etiology is possible. Aortic atherosclerotic change with mural thrombus is noted. There is some focal opacity seen, especially in the right lung with air bronchograms within it. Again, this is presumed to be due to some atelectasis. Posterolaterally within the left lung base there is also a pleural based opacity, again of uncertain significance. Multiple other right lung pleural based opacities are noted. This could be loculated pleural fluid collection, although other etiology, including a nodule, is not even excluded in this scenario. The adrenal glands are within limits as to size. The kidneys are small. A lesion within the spleen is not entirely excluded in this setting. Increased mural thrombus is noted within the aorta at the take-off of the celiac and SMA. On the lung window, there is diffuse increase in the density of the lungs, which is seen within lungs, which are fully expanded. Again seen are the numerous bilateral pleural based opacities as described previously. Nodular density seen is consistent with a subcentimeter calcified granuloma. ABDOMEN AND PELVIS: Mild diffuse fatty infiltration of the liver with no focal hepatic or splenic lesions. There are several lower right rib fractures. NG tube with tip in the proximal stomach. Negative adrenal glands, kidneys, gallbladder. Mild diffuse atrophy of the pancreas. Aortoiliac calcification. The abdominal aorta is of normal caliber. Foley catheter is within the bladder. No free air, free fluid, or adenopathy within the abdomen or pelvis. No fractures are seen involving the spine or pelvis.

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