File

advertisement
PSReport 1201
PATIENT NAME:
DOB:
SEX:
DATE:
Alice Castanza
02/11/XXXX
Female
04/28/20XX
ABDOMINAL AND PELVIC SONOGRAM
FINDINGS
Real-time examination of the upper abdomen is performed. The liver demonstrates normal
echogenicity. No intrahepatic lesions are identified. The gallbladder is normal. There is no
evidence of either intrahepatic or extrahepatic biliary dilatation. The pancreas is unremarkable.
The spleen is normal.
The patient is status post right nephrectomy. No abnormal masses are seen in the right renal
fossa, although it should be noted that the entire area is obscured by overlying bowel gas.
The left kidney is normal in size and echogenicity. It measures 8 cm in length and is unchanged
in size when comparison is made to a study done prior to surgery. On the current exam, there is
mild distension of the left intrarenal collecting system that persisted even following complete
bladder emptying. It is the new finding since the previous exam but is of uncertain clinical
significance due to its very mild degree.
The urinary bladder is scanned and is grossly normal in appearance. A minimal post00void
residual estimated at 35 mL was evident at the conclusion of the study.
IMPRESSION
1. Status post right nephrectomy.
2. No evidence of recurrent tumor in the right renal fossa, although it should be noted that the
entire area is obscured by overlying bowel gas. If clinically indicated, CT imaging or MRI exam
could be performed for further evaluation.
3. Very minimal distension of the left renal pelvis, a new finding since a prior exam. This finding
is of uncertain clinical significance. The left kidney is otherwise normal in appearance.
______________________________
Candace A. Ballantine, MD
CAB/ps
D: 04/28/20XX
T: 04/28/20XX
Download