Примеры описания результатов компьютерной томографии на английском языке

Head CT scan without contrast

Clinical Information: Mrs. Baker is 63 years old and presents with new onset left sided weakness. The onset was sudden and there is a clinical suspicion for an infarct. CT scan was requested to evaluate for a new right sided infarct. (50)
Procedure (CT1): Axial CT scans were obtained from base to vertex without intravenous contrast. No prior studies are available for comparison at the time of this dictation.
Findings: There is an ill-defined area of low attenuation in the posterior limb of the right internal capsule.
The cortical sulci ventricles and cisterns are slightly prominent. There is no mid-line shift, abnormal intra- or extra-axial fluid collection and the brain parenchyma demonstrates no other areas of abnormal density.
The visualized portions of the paranasal sinus, orbits and mastoids are normal.
Impression: Acute infarct in the posterior limb of the right internal capsule.

CT scan of Paranasal Sinuses

Clinical Information: Mr. Baker is 43 years old with a long history of nasal congestion, facial pain and failure to improve on antibiotic treatment. CT of the paranasal sinuses was requested to evaluate for acute/chronic sinusitis (20).
Procedure: Coronal thin sectioned CT scans were obtained through the paranasal sinuses without intravenous contrast. There are no prior cross-sectional image studies available for comparison at the time of this dictation.
Findings: The frontal sinuses are clear. The ethmoid sinuses show mucosal thickening on both left and right sides. The maxillary sinus shows mucosal thickening on both sides with an air fluid level on the right side. The osteomeatal complex on the right side is narrowed secondary to a Haller cell and the mucosal thickening. The osteomeatal complex on the left side is narrowed but patent. The sphenoid sinus shows a minimal air fluid level.
The nasal septum is deviated to the right with a nasal septum spur.
Impression: Acute and chronic sinusitis involving all paranasal sinuses.
Blockage of the right osteomeatal complex.
Narrowing of the left osteomeatal complex.

CT scan of Cervical Spine

Clinical Information: Mr. Jones is 43 years old and presents to the Emergency Department after a car accident with injury to the head, neck and face. Plain films were obtained but were not conclusive as to whether he has a fracture of the cervical spine. Therefore, CT scan of the cervical spine with 2D/3D reconstructions was requested (14).
Cervical spine CT Procedure (Spine 78): Contiguous axial tomographic sections were obtained through the cervical spine without intravenous contrast.
2D Reconstruction: Sagittal and coronal 2D reconstructions were performed to evaluate vertebral height and alignment, neural foramina, and intervertebral disk spaces.
Findings: The alignment, vertebral body and disk space height are normal. There are no subluxations.
Axial images through the spine demonstrate a fracture of a small osteophyte anteriorly inferiorly at C6. This does not involve the spinal canal or the neural foramina.
The soft tissues in front of the upper cervical spine are normal.
Impression: Minimal fracture of osteophyte anterior to C6.

CT scan of Lumbar Spine

Clinical Information: Mr. Garret is 46 years old and presents after a car accident with injury to the lower back. There is a clinical suspicion of a fracture of the lumbar spine since he has pain and neurologic symptoms (30).
Lumbar Spine CT Procedure (Spine 74): Contiguous axial tomographic sections were obtained through the lumbar spine without intravenous contrast.
2D Reconstruction: Sagittal and coronal 2D reconstructions were performed to evaluate vertebral height and alignment, neural foramina, and intervertebral disk spaces.
Findings: The alignment is normal. The vertebral body and disk space height are normal. There is a fracture of anterior lower endplate of L1 without significant reduction in height. The posterior elements and the posterior wall of the vertebral body is intact.
The soft tissues surrounding the lumbosacral spine are normal.
Impression: L1 inferior endplate fracture.

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